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MILTON  M.   LEONARD,   D.V.M. 


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SURGICAL  AND  OBSTETRICAL 
OPERATIONS 


W.  L.  WILLIAMS 


Professor  of  Surgery  and  Obstetrics  In  the  New  York  State 
Veterinary  College,  Cornell  University 


Embodying  portions  of  the  OPERATIONSCURSUS  of  Dr.  Pfeiffer, 

Professor  of  Veterinary  Science  in  the 

University  of  G lessen 


THIRD  EDITION,  REVISED  AND  ENLARGED 


1912 

CARPENTER  &  COMPANY 

ITHACA.  N.  Y. 


Copyright,  1912 

BY 

CARPENTER  &  CO. 


Press  of 

Andrus  &  Church 

Ithaca,  N.  Y. 


PREFACE  TO  THE  THIRD  EDITION. 

The  author  caused  to  be  published  in  1900  a  booklet 
entitled  :  "  A  Course  in  Surgical  Operations  by  W.  Pfeiffer 
and  W.  L.  Williams,"  consisting  of  an  authorized  transla- 
tion of  Dr.  Pfeiffer's  Operating-Cursus  with  such  changes, 
additions  and  omissions  as  were  deemed  desirable.  Three 
years  of  constant  use,  with  such  criticisms  as  came  to  the 
author  from  others,  served  to  point  out  desirable  changes 
of  so  sweeping  a  character  as  to  demand  a  practically  new 
treatise  specially  adapted  to  American  conditions,  and  to 
render  the  continuance  of  a  formal  joint  authorship  inex- 
pedient and  in  1903  the  author  published  a  more  extended 
volume  under  the  present  title,  followed  by  a  large  second 
edition  in  1906.  In  this  third  edition  the  author  has  con- 
tinued to  draw  freely  upon  Dr.  Pfeiffer's  Operations-Cursus 
in  the  preparation  of  the  text  which  in  many  chapters  is 
practically  copied  therefrom,  including  the  illustrations  with 
grateful  acknowledgement  of  his  profound  obligations.  On 
the  other  hand  nothing  has  been  copied  or  extracted  except 
it  could  be  freely  adopted  as  the  author's  own  view,  releas- 
ing Dr.  Pleiffer  from  all  responsibility  for  the  character 
of  .any  of  the  contents. 

The  volume  is  primarily  designed  for  the  use  of  the  au- 
thor's classes  in  laboratory  surgery  and  embryotomy  in  which 
the  student  performs  the  surgical  operations  described,  on 
animals  procured  for  the  express  purpose,  under  chloroform 
anaesthesia  whenever  possible,  after  which  the  subject  is 
destroyed  while  still  anaesthetized  ;  at  the  same  time  it  has 
been  aimed  to  render  the  volume  of  the  greatest  possible 
value  to  the  practitioner  consistent  with  this  plan.  The 
operations  included  under  this  scheme  are  necessarily  limited 
to  those  which  can  be  reasonably  well  performed  on  com- 
paratively sound  animals  of  little  value  and  regularly  pro- 
curable for  laboratory  purpo.ses.     The   list   covers  a  wide 


iv  PREFACE  TO  THE  THIRD  EDITION. 

range  and  is  designed  to  give  to  the  student  as  thorough 
training  as  is  practicable  in  a  laboratory  course  and  includes 
well  nigh  all  the  more  important  varieties  of  confinement, 
anaesthesia,  disinfection,  sutures,  bandaging,  dressing  and 
other  adjuncts  to  operative  work.  The  chapter  on  trephin- 
ing of  the  facial  sinuses  has  been  dealt  with  at  much  greater 
length  in  the  present  edition  in  order  to  fully  and  clearly 
describe  the  author's  method  of  operating. 

The  operation  for  the  surgical  relief  of  roaring  in  horses 
has  undergone  a  complete  revolution  since  the  publication 
of  our  second  edition  in  1906  and  the  technic  therefor  which 
we  had  begun  to  develop  in  1905  and  tentatively  inserted 
in  the  second  edition  has  undergone  phenomenally  rapid 
changes  until  now  it  would  appear  that  the  technic  had 
acquired  a  certain  degree  of  permanency,  though  still  too 
new  to  expect  it  to  remain  unchanged.  The  introduction 
of  the  ventricular  burr  by  Dr.  J.  H.  Blattenberg  and  various 
suggestions  in  the  details  of  technic  by  Prof.  Hobday  of 
England  and  others  has  materially  aided  in  bringing  the 
operation  to  its  present  state  of  reliability  and  caused  the 
operation  introduced  by  us  in  1905  to  become  accepted 
throughout  America  and  Europe  to  the  exclusion  of  other 
methods.  We  have  accordingly  omitted  the  chapter  on 
arytenectomy  from  this  edition,  as  an  obsolete  operation 
and  have  inserted  an  entirely  new  chapter  upon  the  opera- 
rion  for  roaring  in  which  we  have  endeavored  to  bring  the 
technic  thoroughly  up  to  date. 

Generally  but  one  method  of  operating  is  described,  the 
one  chosen  being  that  which  in  the  author's  experience  has 
proven  the  most  valuable  in  actual  practice,  and  no  opera- 
tion has  been  introduced  purely  for  practice  but  each  one 
has  been  tested  and  known  to  have  practical  value. 

When  two  methods  of  operating  are  given,  they  are 
inserted  because  each  has  definite  points  of  superiority  over 
the  other  and  one  method  may  be  specially  applicable  in  a 


PREFACE   TO  THE  THIRD  EDITION.  v 

given  case,  another  in  a  different  patient  where  the  same 
operation  is  to  be  performed  as  for  example,  a  milk  cow  is 
best  spayed  through  the  vagina  while  a  heifer  must  be 
operated  upon  by  an  incision  through  the  abdominal  walls. 

Considerable  stress  has'been  laid  upon  the  surgical  anato- 
my of  the  parts  involved  in  each  operation  ;  some  uses  of 
the  various  operations  are  mentioned  ;  some  of  the  chief 
dangers  of  each  are  pointed  out  and  in  some  cases  references 
to  literature  upon  the  operation  or  the  diseases  for  which 
the  operation  is  designed,  are  cited. 

Figures  i,  2,  6,  7,  9,  10,  11,  15,  16  and  17  and  Plates  Nos. 
XII,  XIV,  XVI,  XXIII,  XXIV,  XXVII,  XXVIII, 
XXIX,  XXXI,  XXXIV,  XXXV,  are  from  Dr.  Pfeiffer's 
Operations-Cursus  ;  and  the  remaining  Plates  and  figures 
were  either  drawn  under  the  direction  of  the  author  by 
Mr.  C.  W.  Furlong,  formerly  instructor  in  Industrial  Draw- 
ing and  Art  in  Sibley  College,  Cornell  University,  or  were 
made  from  original  photographs. 

W.  Iv.  Williams. 

Cornell  University,  March,  igi2. 


CONTENTS. 

I. 

I.  OPERATIONS  ON   THE    HEAD  : 

Page. 

Extraction  of  Teeth i 

Repulsion  of  Teeth 8 

Trephining  the  Facial  Sinuses 16 

Trephining  of  the  Frontal  Sinuses 19 

Trephining  the  Superior  Maxillary  Sinuses 32 

Trephining  the  Inferior  Maxillary  Sinuses 41 

Trephining  the  Nasal  Fossae 45 

Poll  Evil  Operation 53 

Ligation  of  the  Parotid  Duct 61 

Entropium  Operation 62 

Staphylotomy 63 

Trifacial  Neurotomy 64 

II.  OPERATIONS   ON  THE   NECK  : 

opening  the  Guttural  Pouches ^.  70 

Tracheotomy 76 

The  Operation  for  Roaring 78 

Intra-tracheal  Irrigation 87 

Intravenous  Injection 88 

a.  Phlebotomy  with  Fleams 91 

b.  Phlebotomy  with  Lancet 92 

c.  Phlebotomy  with  Trocar 93 

Ligation  of  the  Carotid  Artery 93 

CEsophagotomy 98 

III     OPERATIONS  ON  THE  TRUNK  AND  ON  THE  GENITAL  ORGANS  : 

Puncture  of  the  Chest 100 

Puncture  of  the  Intestine _.  loi 

Subcutaneous  Caudal  Myotomy 103 

Caudal  Myectomy  for  Gripping  of  the  Reins 105 

Amputation  of  the  Tail 109 

Urethrotomy .__ 114 

Amputation  of  the   Penis 117 

Vaginal  Ovariotomy  in  the  Mare 123 

Vaginal  Ovariotomj'in  the  Cow 130 

Ovariotomy  in  the  Cow  by  the  Flank 133 


CONTENTS  vii 

Ovariotomy  in  the  Bitch  by  the  Flank 134 

Ovariotomy  in  the  Bitch  by  the  Linea  Alba 141 

Ovariotomy  in  the  Cat 142 

Castration  of  Cryptorchid  Horses 143 

IV.    OPERATIONS   ON  THE   EXTREMITIES  : 

Tenotomy  of  the  Flexor  Tendons  of  the  Foot 154 

Tenotomy  of  the  Peroneal  Tendon  (Stringhalt  Operation) 157 

Tenotomy  of  the  Cunean  Tendon  (Spavin  Operation) 159 

Neurotomy 161 

Digital  Neurotomy 167 

Plantar  Neurotomy 169 

Median  Neurotomy 1 74 

Ulnar  Neurotomy 179 

Sciatic  Neurotomy 1S5 

Anterior  Tibial  Neurotomy 191 

Resection  of  the  Lateral  Cartilages 196 

Resection  of  the  Flexor  Pedis  Tendon 202 

Amputation  of  the  Claws  of  Ruminants 204 

Bayer's  Sutures 209 

II. 

EMBRYOTOMY   OPERATIONS  : 

Cephalotomy 212 

Decapitation   214 

Subcutaneous  Amputation  of  Ant'irior  L,imb 215 

Amputation  at  the  Humero-radial  Articulation 21S 

Detruncation 21S 

Destruction  of  the  Pelvic  Girdle,  Anterior  Presentation 222 

Amputation  of  the  Limbs  at  the  Tarsus 226 

Intra-pelvic  Amputation  of  the  Posterior  Limbs,  Breech   Pre- 
sentation    230 

Evisceration  of  the  Fetus 239 


INTRODUCTION. 

Man}'  details  must  be  omitted  in  the  succeeding  text  which 
are  of  importance  in  each  operation,  but  which,  if  inserted, 
would  render  the  volume  unwieldy  in  size  for  the  purpose 
designed. 

These  details  are  in  a  measure  alike  in  each  case,  and  it  is 
assumed  that  the  student  has  already  familiarized  himself 
with  them.  The  more  important  of  these  may  be  summa- 
rized as  follows  : 

1.  The  subject  should  be  securely  confined  in  each  case 
as  directed,  because  the  method  designated  has  been  found 
effective  in  the  operation  under  description,  and  serves  to  fix 
the  relations  of  the  parts  in  such  a  way  as  to  conform  to  the 
surgical  anatomy  of  the  region  as  outlined  in  the  text.  It 
is  to  be  constantly  borne  in  mind  that  a  change  in  the  atti- 
tude of  the  animal  may  cause  profound  alterations  in  the 
relations  of  parts  which  displacement  may  greatly  embarass 
the  operator,  or  even  prevent  his  carrying  out  the  operation 
according  to  the  technic  given.  In  securing  an  animal  for 
operation  the  whole  body  should  be  confined  in  a  way  that 
will  sufficiently  control  movements  and  will  insure  safety  to 
the  patient  and  operator  ;  the  part  to  be  operated  upon  must 
be  so  fixed  as  to  properly  limit  its  motion  and  in  a  position 
to  afford  the  greatest  facility  for  the  carrying  out  of  the 
operation  according  to  the  technic  given. 

2.  Anaesthesia  should  be  carefully  carried  out  everywhere 
possible,  because  in  addition  to  the  humane  sentiments  in- 
volved, the  resulting  perfect  control  of  the  animal  is  an 
essential  in  aseptic  or  antiseptic  surgery.  The  student 
should  make  a  careful  study  of  anaesthesia  in  these  exercises 
and  acquire  invaluable  experience  and  confidence  for  their 
use  in  actual  practice. 


X  INTRODUCTION. 

3.  Disinfection  must  be  scrupulously  applied  in  every  de- 
tail since  upon  its  effectiveness  must  rest  the  verdict  of 
success  or  failure  as  measured  by  modern  surgical  thought. 
The  operator's  finger  nails  should  be  well  trimmed,  smoothed 
and  cleansed,  and  his  hands  and  arms  thoroughly  scrubbed 
with  a  stiff  brush  in  hot  water  and  soap  for  a  period  of  fifteen 
minutes,  and  all  dirt  and  old  epidermal  scales  removed. 
The  parts  should  then  be  disinfected.  This  ma}^  be  accom- 
plished by  immersing  the  hands  in  a  hot  concentrated  solu- 
tion of  permanganate  of  potassium  for  ten  minutes  and  then 
decolorizing  them  in  a  strong  solution  of  oxalic  acid  in  boiled 
water. 

Or  the  hands  may  be  disinfected  after  the  washing  with 
soap  and  water  by  immersing  and  scrubbing  them  for  ten 
minutes  in  a  i  to  1000  solution  of  corrosive  sublimate,  but 
in  order  to  make  this  thoroughly  effective  the  solution  needs 
be  alcoholic,  or  the  hands  should  first  be  immersed  in 
alcohol,  ether,  or  other  substance  capable  of  dissolving  fats 
and  permitting  the  disinfectant  to  penetrate  to  every  part 
without  being  obstructed  by  sebum  or  fat.  Great  care 
should  be  exercised  by  the  student  not  to  touch  au}'  object 
with  his  hands  after  they  have  been  disinfected  for  the 
operation,  unless  such  object  has  also  been  disinfected  or 
sterilized,  or  in  case  it  becomes  necessary  to  touch  objects 
not  sterile,  the  disinfecting  process  should  be  repeated  before 
proceeding  further  with  the  operation.  This  constitutes 
one  of  the  most  difficult  of  all  details  for  the  beginner  to 
acquire,  and  each  failure  should  be  remedied  by  repeating 
the  process  over  and  over  until  the  habit  of  maintaining 
effectual  asepsis  is  acquired  and  fixed. 

The  operative  field  should  always  be  carefully  shaved  be- 
fore beginning  the  operation,  and  the  shaved  area  should 
always  be  ample,  so  as  to  insure  against  contamination 
from  adjacent  hairs,  as  well  as  to  give  a  clear  view  of  the 
field.     The   area   should   then  be  disinfected   in   a  reliable 


INTRODUCTION.  xi 

manner,  that  advised  for  the  operator's  hands  serving  as  a 
type.  Whenever  circumstances  will  permit  the  operative 
field  should  be  kept  in  an  antiseptic  bath  or  pack  for  twenty- 
four  hours  prior  to  the  operation  in  order  that  the  deeper 
parts  of  the  skin,  especially  the  hair  follicles  and  sebaceous 
glands,  shall  become  thoroughly  disinfected,  a  process  well 
nigh  impossible  in  a  short  period. 

The  suturing,  dressing  and  bandaging  of  the  wound 
should  be  carried  out  carefully  in  every  case  and  no  opera- 
tion left  without  completing  it  in  the  best  manner  possible. 

The  student  should  make  each  operation  as  real  as  possible 
and  not  omit  any  detail  even  if  he  thinks  he  already  knows 
it  sufficiently  well,  as  the  repetition  of  a  supposedly  familiar 
detail  serves  an  important  purpose  in  the  fixing  of  a  habit 
which  is  inestimably  more  valuable  to  the  surgeon  than  any 
theoretical  knowledge  of  technic. 

The  safe  surgeon  is  he  who  has  so  accustomed  himself  to 
the  technique  of  asepsis  and  antisepsis  that  he  carries  it  out 
rigidly  in  an  automatic  manner  and  is  thus  free  to  concen- 
trate his  entire  attention  on  the  surgical  problems  before 
him. 

The  student  who  consults  his  interests  will  go  yet  farther 
and  prior  to  undertaking  any  operation  on  the  living  subject 
will  study  the  regional  anatomy  of  the  part  on  the  cadaver 
and  learn  therefrom  all  that  he  can  of  the  structure  of  the 
part  which  he  must  finally  complete  upon  the  living  animal. 
No  dissection  of  the  cadaver  can  ever  teach  true  surgical 
structure  as  the  dead  tissues  can  not  be  like  the  living,  but 
such  dissection  can  and  does  give  great  aid  and  should  be 
pursued  as  far  as  it  can  lead  and  enough  will  still  remain  to 
be  learned  on  the  living  subject.  It  is.  to  be  constantly  re- 
membered that  afiatomy  deals  with  the  structure  of  the  dead 
body  while  surgical  operations  are  performed  upon  the 
living  structures  :  they  are  not  alike. 


xii  INTRODICTION. 

The  student  should  further  take  occasion  to  study  in  con- 
nection with  each  operation  the  object  or  objects  for  which 
it  is  performed  in  practice,  its  effect  on  the  diseased  or  other 
parts,  the  untoward  results  to  be  anticipated,  etc. 

Suggestions  occur  from  time  to  time  in  the  text  designed 
to  aid  the  student  in  these  lines  and  help  weave  connecting 
bonds  between  the  operation,  its  objects  and  results. 

Surgical  operations  may  in  themselves  be  valueless  or 
worse  and  acquire  value  only  when  properly  correlated  to 
disease  and  skillfully  performed. 


Surgical  and  Obstetrical  Operations. 


I.  SURGICAL  OPERATIONS. 

I.  OPERATIONS  ON  THE  HEAD. 
TOOTH  OPERATIONS. 

Prefatory  remarks.  The  grinding  teeth  of  the  horse 
consisting  ot  three  premolars  and  three  molars  in  each  row 
are  of  such  dimensions  and  attachments  that  their  removal 
in  case  of  disease  or  defect  often  presents  difficulties  of  no 
small  degree. 

These  teeth  attain  their  greatest  size  at  the  time  of  erup- 
tion and  most  of  each  tooth  remains  firmly  imbedded  in  its 
alveolus  while  a  very  shallow  crown  projects  into  the  buccal 
cavity.  The  teeth  are  gradually  pushed  out  of  their  alveoli 
as  their  crowns  are  worn  away  by  attrition  as  age  advances 
and  the  proportion  of  the  intra-  to  the  extra-alveolar  part 
gradually  decreases  until  in  very  old  animals  the  alveoli  be- 
come obliterated  and  the  last  vestige  of  what  was  once  the 
apex  of  the  fang  rests  insecurely  in  the  buccal  mucosa. 

The  facility  with  which  teeth  may  be  extracted  increases 
as  the  age  of  the  animal,  being  as  a  rule  easily  drawn  with 
forceps  in  old,  while  in  case  of  freshly  erupted  teeth  in 
young  horses  it  may  be  almost  or  quite  impossible  to  extract 
them  with  forceps  of  any  kind,  except  in  those  cases  where 
they  have  become  somewhat  loosened  as  the  result  of  disease 
or  accident.  When  aberrations  in  development  occur,  lead- 
ing to  the  formation  of  dental  tumors  or  odontomes  the 
possibility  of  extraction  by  means  of  forceps  is  frequently 
wholly  excluded.  In  cases  where  dental  disorder  has  led  to 
empyema  of  the  facial  sinuses,  even  if  the  tooth  may  be 
drawn  by  means  of  forceps,  further  operation  is  generally 


2  EXTRACTION  OF  TEETH. 

necessary,    in  order  to  assure  a  prompt   recoverN",   by   the 
removal  of  the  effects  of  the  disease  of  the  tooth. 

The  removal  of  molars  may  therefore  involve  extraction 
with  forceps,  trephining  the  dental  alveolus  and  repulsion 
of  the  tooth  and  trephining  of  the  sinuses  because  of  em- 
pyema or  other  pathologic  conditions  referable  to  the  dental 
affection  ;  consequently  all  of  these  should  be  studied  as 
related  topics. 

1.     EXTRACTION  OF  TEETH. 
Plates  I  and  II. 

Instruments.  Extracting  forceps,  fulcra  of  various 
sizes,  mouth  speculum  with  abundant  lateral  working  room, 
exporteur  forceps,  toothpick,  splinter  forceps,  reflecting 
lamp. 

Technic.  In  simple  cases  with  a  quiet  animal  the  pa- 
tient may  be  sufficiently  confined  by  being  backed  into  a 
corner  or  very  much  better  by  securing  in  stocks.  In  com- 
plicated cases  or  very  resistant  animals  it  is  best  to  place 
the  patient  upon  the  operating  table  or  in  default  of  this, 
cast  and  secure  in  lateral  recumbence  on  the  sound  side. 

Apply  the  speculum  and  identify  the  diseased  tooth  by 
manual  exploration  ;  determine  if  the  tooth  is  of  unnatural 
size  or  form,  if  it  is  loose,  if  the  gums  are  separated  from  the 
neck  at  any  point,  if  it  is  out  of  line  with  the  other  teeth  in 
the  row,  if  it  is  painful  to  the  touch,  if  it  be  split,  etc.  An 
external  tooth  fistula  or  a  tumefaction  over  the  affected 
member  may  aid  in  distinguishing  it.  Aid  may  also  be  had 
by  illuminating  the  mouth  with  a  reflecting  electric  or  other 
lamp. 

Remove  any  accumulations  of  partiall)-  masticated  food 
by  means  of  the  toothpick  or  fingers. 

In  applying  the  forceps,  have  an  assistant  draw  the 
tongue  out  at  the  commissure  of  the  lips  on  the  side  oppo- 


EXTRACTION  OF  TEETH.  3 

site  to  the  affected  member  and  introducing  one  hand  into 
the  mouth,  place  the  index  finger  on  the  posterior  border 
of  the  diseased  tooth  and  with  the  other  hand,  push  the 
opened  forceps  backward  upon  the  dental  row  until  they 
reach  the  diseased  member,  then  firmly  grasp  it  with  the 
instrument,  pressing  the  jaws  down  as  deeply  as  possible 
against  the  alveolus. 

In  many  cases  the  diseased  tooth  can  be  clearly  seen, 
especially  with  the  aid  of  the  reflecting  lamp,  and  the 
forceps  may  be  readily  applied  by  sight,  which  is  frequently 
preferable  to  the  sense  of  touch. 

Withdraw  the  free  hand  from  the  mouth,  grasp  the 
forceps  handles  firmly  and  loosen  the  tooth  in  its  alveolus 
by  establishing  and  maintaining  as  long  as  necessary  a  gentle 
to  and  fro  lateral  movement.  The  tooth  is  thus  loosened  in 
its  alveolus  by  causing  it  to  revolve  very  slightly  back  and 
forth  on  its  long  axis,  thereby  spreading  the  alveolar  cavity. 
When  the  tooth  has  become  well  loosened,  the  fact  is  indi- 
cated by  its  revolving  with  the  forceps  and  by  an  audible 
crepitant  sound  caused  by  the  passage  of  air  bubbles  to  and 
fro  through  the  blood  and  lymph  in  the  alveolus.  Maintain 
the  forceps  in  position  with  one  hand  and  with  the  other 
introduce  the  fulcrum  to  a  point  where  the  depression  on  its 
superior  surface  will  receive  the  projecting  rivet-head  of  the 
instrument  or  in  an  otherwise  secure  position  affording  a 
safe  support,  while  the  inferior  surface  rests  evenly  upon 
the  crown  of  a  tooth  anterior  to  that  which  it  is  desired  to 
extract,  as  is  shown  in  Plate  I.  The  fulcrum  needs  be  held 
firmly  in  place  in  order  to  prevent  it  from  gliding  away 
under  pressure. 

In  extracting  the  first  premolars  there  is  no  opportunity 
for  resting  the  fulcrum  on  teeth  anterior  thereto  and  con- 
sequently forceps  have  been  made  with  fulcra  beyond  the 
forceps  jaws  resting  upon  teeth  more  posteriorly  situated. 
This  is  not  essential.     If  the  tooth  is  thoroughly  loosened. 


Plate  J. 
Extraction  of  Teeth. 

Sagittal  section  through  the  oral  cavity,  show- 
ing plan  for  extracting  the  third  inferior  pre- 
molar, viewed  from  within  the  mouth. 

A  Forceps  jaws  applied  to  third  premolar. 

B  Fulcrum  resting  upon  first  premolar. 

CC,  Plates  of  mouth  speculum  resting  upon 
incisor  teeth. 


EXTRACIION  OF  TEETH.  7 

as  it  should  be,  one  hand  placed  in  the  interdental  space 
with  the  dorsal  surface  against  the  jaw  and  the  volar  grasp- 
ing the  instrument,  will  serve  as  an  effective  fulcrum. 

In  other  cases  an  iron  or  steel  fulcrum  is  not  essential, 
but  a  stick  of  hard  wood  of  proper  size  and  form  acts  quite 
as  efficientlj'  and  may  even  keep  its  position  better  because 
the  teeth  upon  which  it  rests  sink  into  it  somewhat.  On 
the  whole  the  fulcrum  is  not  so  important  as  some  have 
considered  it,  since,  after  a  tooth  is  loose  enough  to  be 
drawn  with  its  aid,  a  very  trifling  additional  loosening  will 
permit  it  to  be  easily  lifted  from  its  alveolus  without  it. 

The  tooth  fang  is  extracted  by  forcing  the  handles  of  the 
forceps  toward  the  jaw  in  which  it  is  located,  so  that  as  it 
is  gradually  drawn  out  the  forceps  tend  to  pivot  on  the 
fulcrum  in  a  way  to  permit  the  tooth  to  emerge  from  its 
alveolus  in  the  direction  of  its  long  axis.  By  referring  to 
Plate  II  it  will  be  seen  that  the  long  axes  of  the  different 
teeth  vary,  that  of  the  molars  being  obliquely  forwards  from 
fang  to  crown  towards  the  incisors,  while  the  crowns  of  the 
premolars  are  directed  obliquely  backwards  toward  the 
molars.  The  slant  of  the  teeth  is  most  marked  at  the  ends. 
of  each  arcade  while  at  the  middle  they  acquire  an  almost 
perpendicular  position. 

In  drawing  the  last  molar  the  back  of  the  forceps  will, 
generally  strike  against  the  opposite  dental  arcade  before 
the  tooth  has  completely  emerged  from  its  alveolus  and  im 
order  to  complete  its  removal  it  may  be  necessary  to  take 
a  deeper  hold  with  the  extracting  forceps  or  withdrawing 
these  complete  the  operation  with  the  aid  of  exporteur 
forceps,  or  still  better  frequently  with  the  hand.  In  young 
horses  where  the  teeth  are  very  long  we  have  found  it  im- 
possible to  complete  the  extraction  until  the  tooth  had  been 
divided  transversely  by  means  of  the  tooth  cutting  forceps. 

The  dangers  in  the  extraction  of  teeth  are  chiefly  : 

I.  The  transverse  fracture  of  the  tooth,  leaving  the  fang 
still  fixed  in  the  alveolus,    a  danger  not  infrequently  un- 


8  REPULSION  OF  TEETH. 

avoidable  when  the  crown  has  become  greatly-  weakened  by 
disease  so  that  it  lacks  the  necessar)^  power  of  resistance  ; 
under  most  other  conditions  transverse  fracture  may  be 
largely  guarded  against  by  the  careful  securing  of  the 
patient  in  a  manner  to  effectively  prevent  sudden  throwing 
of  the  head  while  the  forceps  are  applied,  and  by  using  good 
judgment  in  the  amount  of  force  exerted  while  loosening 
the  tooth  in  its  alveolus.  As  stated  above  we  should  not 
expect  to  be  able  to  extract  with  forceps  the  teeth  of  very 
young  horses  which  have  not  become  partly  detached  by 
disease  or  in  which  the  fangs  are  the  seat  of  odontomes. 

2.  Fracture  of  the  alveolar  walls  is  an  accident  which 
may  generally  be  prevented  by  proper  care  in  the  application 
of  force  and  the  avoidance  of  any  attempt  to  extract  a  tooth 
when  the  existence  of  an  enlargement  of  the  fang  is  apparent 
or  suspected. 

3.  The  tooth  may  slip  from  the  forceps  into  the  pharynx 
and  be  swallowed,  an  accident  avoidable  by  inserting  the 
hand  into  the  mouth  as  the  tooth  begins  to  emerge  from  its 
alveolus,  and  if  need  be,  grasp  it  with  the  fingers. 


2.     REPULSION  OF  TEETH. 
Plate  II. 

Uses.  The  removal  of  molars,  pre-molars,  tooth  fangs 
from  which  the  crowns  have  been  broken  away,  alveolar 
odontomes,  etc.,  which  can  not  be  removed  safely  by  means 
of  the  forceps. 

Instruments.  Mouth  speculum,  razor,  convex  scalpels, 
trephine,  bone  gouge,  Luer's  sharp  bone  forceps,  (rongeur 
forceps)  light  and  heavy  bone  chisels,  mallet,  tooth  punch, 
curette,  compression  artery  forceps,  .scissors,  needles,  thread, 
absorbent  cotton,  antiseptic  gauze,  extracting  forceps, 
splinter  forceps,  tenacula,  metal  probe. 


REPULSION  OF  TEETH.  9 

Technic.  Secure  the  animal  in  the  lateral  recumbent 
position  with  the  affected  side  up.  The  operating  table 
affords  hy  far  the  best  means  for  securing  for  the  conven- 
ience and  safety  of  operator  and  patient.  If  the  sinuses  are 
so  involved  as  to  make  possible  the  inhalation  of  pus,  blood 
or  other  injurious  matter,  perform  tracheotomy  in  ample 
time  to  avert  danger.  Anaesthetize  locally  or  generally  as 
required.  Shave  and  disinfect  the  operative  area  and 
trephine  according  to  the  method  described  in  the  following 
chapter,  down  through  the  alveolar  plate  immediately  over 
the  fang  of  the  affected  tooth.  Avoid  dulling  the  trephine 
by  striking  it  against  the  tooth  fang. 

If  an  external  fistula  exists  the  identity  of  the  affected 
tooth  is  best  determined  by  passing  a  metallic  probe  through 
it  against  the  diseased  fang  while  one  hand  is  passed  into 
the  mouth  and  the  location  of  the  probe  more  fully  ascer- 
tained. Care  should  be  exercised  in  trephining  to  not  injure 
the  adjoining  teeth. 

After  removing  the  disc  of  bone  isolated  by  the  trephine, 
control  all  hemorrhage  and  then  enlarge  the  opening  and 
remove  the  bony  tissues  till  the  tooth  fang  is  bared  its  entire 
width.  Insert  a  scalpel  or  bone  chisel  between  the  external 
face  of  the  bone  and  the  soft  tissues  at  the  oral  margin  of 
the  trephine  opening  and  with  one  hand  in  the  oral  cavity 
with  the  fingers  resting  upon  the  alveolar  border  on  the 
lateral  side  of  the  tooth  to  serve  as  a  guide,  push  the  scalpel 
or  chisel  along  between  the  bone  and  soft  tissues  until  it 
emerges  from  the  gums  alongside  the  affected  tooth  and 
extend  this  separation  backwards  and  forwards  until  the 
soft  tissues  are  completely  detached  from  the  alveolar  wall 
over  the  entire  area  of  the  diseased  member. 

When  operating  upon  the  superior  molars,  the  fangs  of 
which  are  covered  by  the  zygomatic  ridge,  the  chisel  or 
scapel  cannot  be  pushed  directly  from  the  trephine  opening 
into  the  mouth  between  the  soft  tissues  and  the  bone  because 
the  line  is  concave  instead  of  direct.     In  these  cases  it  is 


o   o 


REPULSION  OF  TEETH.  13 

best  to  detach  the  soft  parts  from  the  zygoma  onl}'  at  first 
and  then  remove  the  alveolar  plate  of  the  ridge  with  the 
bone  forceps  or  chisel,, after  which  the  line  into  the  mouth 
is  direct  and  the  instrument  can  then  be  readily  pushed  be- 
tween the  soft  and  osseous  tissues  for  the  remainder  of  the 
distance  and  the  separation  completed. 

In  operating  upon  the  inferior  molars  covered  by  the 
masseter  an  opening  through  the  muscle  may  be  made  near 
its  lower  border  large  enough  to  admit  the  trephine  or  the 
muscle  may  be  detached  at  its  point  of  insertion  to  the 
inferior  maxillary  bone  and  two  parallel  incisions  carried 
upwards  a  short  distance,  permitting  the  raising  of  a  flap, 
or  what  is  generally  best  for  the  second  and  third  molars,  a 
curved  incision  is  made  at  the  antero-inferior  border  of  the 
masseter  muscle  parallel  to  the  parotid  duct  and  satellite 
vessels  and  just  posterior  to  them  and  the  muscle  lifted  up 
and  drawn  backwards  sufficiently  to  expose  the  bone  im- 
mediatel}^  over  the  tooth  fang. 

With  a  light,  narrow  bone  chisel  cut  away  and  remove 
the  external  alveolar  plate  over  the  entire  extent  of  the 
tooth,  from  the  oral  margin  of  the  trephine  opening  into- 
the  mouth  cavity.  Hold  the  chisel  so  that  the  outer  edge  is 
inclined  from  the  affected  tooth  toward  the  adjoining  one, 
thus  making  a  bevelled  channel  through  the  alveolar  plate 
tending  to  loosen  the  isolated  section  of  bone  by  driving  it 
outwards.  Drive  the  chisel  for  a  short  distance  on  one 
side,  then  upon  the  other,  and  thus  break  the  alveolar  plate 
away  in  small  sections  and  avoid  an  extension  of  the 
fracture  to  neighboring  alveoli  and  damage  to  adjacent 
teeth.  Care  should  be  taken  that  the  bone  chisel  is  sharp 
otherwise  extensive  fractures  of  the  bone  may  occur.  With 
gouge  and  chisel  remove  all  remnants  of  bone  over  the 
lateral  side  of  the  tooth  lajdng  it  completely  bare  as  shown 
in  Plate  II. 

The  soft  tissues  of  the  part  should  not  be  disturbed 
beyond  the  excision  of  the  circular  piece,  corresponding  to- 


14 


REPULSION  OF  TEETH. 


the  disk  of  bone  removed  by  the  trephine  and  the  detaching 
of  them  from  the  portion  of  bone  to  be  chiseled  away. 

When  the  tooth  has  been  bared  so  that  every  part  of  its 
lateral  surface  can  be  seen  or  felt,  the  punch  may  be  placed 
against  the  end  of  the  fang,  a  few  firm,  quick  blows  given 
with  the  mallet,  so  directed  that  the  force  is  in  a  line  with 
the  long  axis  of  the  tooth,  and  the  organ  driven  into  the 
mouth  where  it  is  seized  by  the  forceps  or  the  hand  and- 
removed.  If  it  is  not  readily  and  safely  dislodged  in  this 
way,  place  the  heavy  bone  chisel  against  it  and  with  the  aid 
of  the  mallet  comminute  the  tooth  by  breaking  it  trans- 
versely and  splitting  it  longitudinally,  in  which  process  the 
fragments  are  generally  loosened  from  the  alveolar  walls  and 
can  then  be  readily  removed  wath  the  aid  of  the  gouge,  or 
heavy  dressing  or  splinter  forceps.  Remove  carefully  all 
fragments  of  tooth  or  of  loosened  bone,  cleanse  and  disinfect 
the  wound,  pack  with  iodoform  gauze  and  dress  daily. 

In  cases  where  a  fistulous  opening  remains  after  repulsion 
of  molars  without  the  removal  of  the  alveolar  wall,  or  if  a 
tooth  has  been  drawn  by  means  of  the  forceps  and  the 
alveolus  fails  to  heal,  the  bony  plate  should  be  removed  in 
the  above  manner. 

Dangers.  Wounding  of  the  adjoining  tooth  is  to  be 
avoided  chiefly  by  carefully  locating  the  fang  of  the  affected 
one  and  placing  the  instrument  as  exactly  as  possible  over 
its  centre,  by  using  a  trephine  not  exceeding  2  to  2.5  cm.  in 
diameter  and  cautiously  sawing  through  the  compact  layer 
of  the  external  plate  only,  removing  the  cancellated  tissue 
with  the  gouge  and  extending  the  opening  in  the  desired 
■direction  after  the  outlines  of  the  tooth  fang  have  been 
clearly  determined.  If  an  adjoining  fang  is  wounded,  the 
tooth  should  be  removed  as  it  will  not  heal  but  will  result 
in  a  permanent  tooth  fistula. 

Fracture  of  the  alveolar  walls  of  the  inferior  maxilla 
may  occur  during  the  removal  of  the  external  alveolar  plate 
-with  the  chisel  or  of  the  repulsion  of  the  tooth  with  the 


REPULSION  OF  TEETH.  15 

punch.  The  first  is  to  be  averted  by  care  in  having  the 
chisel  sharp,  by  observing  the  precaution  of  making  a 
bevelled  cut  through  the  bone,  by  using  only  moderate 
blows  and  driving  the  instrument  alternately  for  a  short 
distance  on  each  side.  The  second  danger  of  extensive 
fracture  may  be  averted  by  being  cautious  to  see  after  each 
stroke  on  the  punch  that  it  has  not  slipped  inward  along 
the  median  side  of  the  tooth,  pressing  the  internal  plate 
away  from  the  tooth  and  tending  to  produce  a  longitudinal 
fracture  nearly  or  quite  as  long  as  the  dental  arcade. 
Careful  digital  exploration  in  the  mouth  may  discover  this 
fracture  while  still  "simple"  but  a  stroke  or  two  more  will 
convert  it  into  the  very  much  more  serious  "compound" 
fracture  opening  into  the  oral  cavity.  Keeping  one  hand 
constantly  in  the  mouth  at  the  point  of  impact  is  always 
desirable  as  a  precautionary  measure. 

Transverse  fracture  of  the  tooth  while  yet  in  situ  by 
means  of  the  bone  chisel,  as  above  described,  is  a  great  safe- 
guard against  this  injury  by  lessening  the  force  required  in 
repulsion  and  by  the  removal  of  the  tapering  fang,  which 
then  leaves  a  more  secure  base  for  the  punch  to  act  upon. 
It  should  never  be  forgotten  that  the  impact  from  the  punch 
must  always  be  as  nearly  parallel  to  the  long  axis  of  the 
tooth  as  is  possible. 

The  fracture  of  the  superior  maxilla  and  bony  palate  is 
not  so  probable  as  the  preceding  and  is  preventable  by  mod- 
erate care  in  the  denuding  of  the  tooth  before  punching,  by 
comminution  of  the  tooth  in  proper  cases,  by  the  careful  ad- 
justment of  the  punch  and  applying  the  force  in  the  proper 
direction. 

Literature.  Odontomes,  Sir  Bland  Sutton,  Jour.  Comp. 
Med.  and  Vet.  Arch,  Vol.  XII.  p.  i  ;  A  Clinical  Study  of 
Odontomes,  W.  I^.  Williams,  Am.  Vet.  Review,  Vol.  XV, 
p.  I  ;  Notes  on  Odontomes,  do  ;  Am.  Vet.  Rev.  Vol.  XXIII, 
p.  82  and  Oest.  Mon.  Thierheilkunde,  Bd.  XXIV,  s.  122. 


1 6  TREPHINING  OF  THE  FACIAL  SINUSES. 

TREPHINING  OF  THE  FACIAL  SINUSES. 
Plates  III- XL 

Prefatory  Note.  The  facial  sinuses  of  the  horse  consti- 
tute an  exceedingly  intricate  and  extensive  group  of  cavities, 
communicating  more  or  less  freely  with  each  other  or  with 
the  exterior  through  the  medium  of  the  upper  air  passages, 
of  which  they  are  to  be  regarded  as  a  part. 

Their  arrangement  and  relations  permit  them  to  frequently 
become  the  seat  of,  or  central  figure  in  many  forms  of  disease 
which  require  for  their  differential  diagnosis,  amelioration 
or  cure,  the  operation  known  as  trephining.  Their  extent 
and  relations  to  each  other  and  to  surrounding  parts  varies 
greatly  with  age  and  may  be  profoundly  changed  as  a  result 
of  disease,  amounting  not  infrequently  in  the  frontal, 
superior  and  inferior  maxillary  sinuses  ceasing  to  exist  as 
separate  cavities  and  becoming  merged  into  one  vast  diverti- 
culum. The  general  position,  extent  and  relations  of  these 
are  indicated  by  Plates  III-XI. 

It  is  to  be  noted  that  in  cross  .sections  the  superior  and 
inferior  maxillary  sinuses  appear  to  be  reversed  in  relation 
to  their  nomenclature.  It  is  difficult  to  make  a  cross  .sec- 
tion of  these  sinuses  in  such  a  manner  that  the  antero- 
inferior extremity  of  the  superior  sinus  does  not  show  below 
and  external  to  the  inferior  one.  The  inferior  maxillary 
sinus  is  ifi/erior  in  the  sense  that  it  is  nearer  to  the  nasal 
opening  so  that  with  the  head  in  a  vertical  position  or  in  a 
longitudinal  section  the  inferior  sinus  is  below  the  superior, 
while  if  the  head  be  placed  horizontally  or  a  cross  section 
made,  a  small  portion  of  the  superior  sinus  may  show  below 
the  inferior. 

The  uses  of  trephining  are  in  a  measure  common  to  all 
the  sinuses  and  are  chiefly  for  the  relief  of  empyema  of  the 
cavities  involved,  necrosis  of  the  bony  or  cartilaginous  walls,, 
tumors  of  various  kinds,  especially  dental  in  the  young  and 


TREPHINING  OF  THE  FACIAL  SINUSES. 


17 


malignant  growths  in  the  old,  foreign  bodies  in  the  sinuses, 
differential  diagnosis  of  diseases  of  this  region,  etc. 

Veterinarians  trephine  the  sinuses  by  two  fundamentally 
different  plans  ;  with,  and  without  excision  of  the  cutaneous 
disk  corresponding  to  the  piece  of  the  bone  removed.  The 
first  is  generally  used  in  Great  Britain  and  North  America, 
while  the  last  is  the  prevailing  method  in  continental 
Europe  and  other  parts  of  the  world.  The  reason  assigned 
for  these  variations  in  method  are  conflicting.  To  us  there 
seem  to  be  adequate  reasons  for  preferring  the  excision  of 
the  cutaneous  disk.  We  regard  as  the  chief  considerations 
in  an  operation  the  following  :  the  avoidance  of  infection  ; 
the  prevention  of  pain  during  the  operation  or  the  after- 
treatment  ;  the  reduction  of  the  scar  to  a  minimum  ;  rapidity 
and  certainty  of  recovery  ;  convenience  in  operating  and 
dressing.  Inevitably  a  septic  operation,  the  degree  of 
infection  is  largely  dependent  upon  the  area  of  the  wound, 
the  facility  for  maintaining  cleaniness  and  the  degree  of 
disturbance  to  the  tissues  while  being  dressed.  The  wound 
area  in  the  bone  is  alike  in  all  cases  but  that  in  the  skin 
varies  greatly.  If  we  compare  the  usual  European  technic 
with  that  given  below  we  would  find  the  wound  area  ap- 
proximately 2.2  sq.  in.  in  the  European  method,  while  in 
the  latter  we  have  only  about  .44  sq.  in.  or  proportionately 
the  wound  area  in  the  soft  tissues  in  the  two  operations 
would  be  as  5  :  I . 

It  is  very  evident  that  the  technic  given  below  affords 
immeasureably  better  facility  for  maintaining  cleanliness  in 
the  wound  and  with  a  minimum  amount  of  insult  to  the 
tissues  in  the  process  of  dressing. 

The  amount  of  pain  caused  in  the  operation  which  should 
be  eliminated  by  local  anaethesia  depends  chiefly  upon  the 
extent  of  the  skin  incision  which  is  essentially  equal  in  the 
two   plans  .so   that   the  only  difference    would    be    in    the 


1 8  TREPHINING  OF  THE  FACIAL  SINUSES. 

dissection  of  the  skin  from  the  bone  in  the  European 
operation.  The  pain  caused  in  dressing  must  be  greater  in 
the  European  method  because  the  detached,  overhanging 
skin  must  be  moved  and  disturbed  each  time  causing  pain 
and  inviting  infection.  The  question  of  pain  in  dressing 
must  always  be  seriously  considered  as  it  not  only  affects 
the  time  required  for  dressing  and  its  efficacy,  but  has  an 
important  relation  to  the  docility  of  the  animal  after  re- 
covery, some  horses  having  their  dispositions  permanently 
ruined  by  the  irritation  due  to  the  oft  repeated  painful 
dressing  of  wounds. 

The  cicatricial  contraction  of  the  tissues  of  the  horse  is 
so  great  that  the  removal  of  a  circular  disk  of  skin  J^  to  1)4 
in.  in  diameter  on  the  face  does  not  leave  a  visible  scar 
so  that  the  question  of  blemish  falls  back  upon  that  of 
infection,  which,  as  we  have  asserted  above  is  far  more 
probable  by  the  continental  European  method. 

The  rapidity  and  certainty  of  recovery  are  dependent 
upon  the  considerations  above  discussed.  The  removal  of 
the  cutaneous  disk  is  certainly  easier  and  quicker  than  the 
other  method.  The  convenience  for  dressing  is  evidently 
superior  by  the  English  and  American  method. 

The  opening  of  the  sinuses  into  the  nostrils  is  based  upon 
the  surgical  principle  that  suppurating  cavities  should  be 
provided  with  ample  drainage  from  the  most  dependent 
part.  The  direction  to  leave  the  external  wound  open,  at 
first  thought  seems  antagonistic  to  general  surgical  princi- 
ples but  it  should  be  remembered  that  the  wound  consists 
only  of  the  incision  through  the  skin,  connective  tissue 
and  bone  penetrating  a  suppurating  cavity,  and  that  any 
object  which  we  can  place  in  this  opening  can  only  serve 
to  dam  back  the  secretions  of  the  cavity  and  can  not  prevent 
them  from  coming  in  contact  with  the  wounded  surface. 
It  must  further  be  regarded  that  the  respiratory  mucosa  of 
the  upper  air  passages  are  not  irritated  or  injured  in  any 


TREPHINING  OF  THE  FRONTAL  SINUSES. 


19 


manner  so  far  as  we  can  observe  clinically  by  the  direct  ad- 
mission of  air  into  them  through  a  trephine,  or  other  artificial 
opening,  but  on  the  contrary  the  suppuration  in  a  sinus  is 
constantly  aggravated  by  the  retention  of  the  pus  and  ex- 
clusion of  air  and  recovery  facilitated  by  thorough  drainage 
and  aeration. 


3.    TREPHINING  OF  THE  FRONTAL  SINUSES. 
Plates  III-XI. 

Uses.     Fracture  of  the  bonj'  walls,  necrosis,  tumors. 

The  ample  communication  below  with  the  superior 
maxillary  sinus  (See  FE,  Plates  V  and  VI )  prevents  the 
accumulation  of  pus  or  fluids  in  the  frontal  sinuses  even  if 
formed  therein  unless  the  former  becomes  filled  and  the 
contents  back  up  into  the  latter.  In  empyema  of  the 
frontal  sinuses,  trephining  can  not  give  relief,  but  calls  for  a 
repetition  of  the  operation  on  the  maxillary  sinuses. 

Instruments.  Razor,  scissors,  convex  scalpels,  artery 
forceps,  tenacula,  probe,  trephine,  curette,  gouge,  Luer's 
sharp  bone  forceps  (rongeur  forceps),  hammer,  chisel, 
probe-pointed  bistoury,  dressing  forceps,  disinfecting  and 
dressing  materials. 

Technic.  The  operation  may  be  performed  upon  the 
standing  animal  with  the  aid  of  local  anaesthesia  of  the 
skin,  the  bone  having  virtually  no  sensation.  Restless 
animals  may  be  further  secured  with  the  twitch,  in  the 
stocks,  upon  the  operating  table  or  bj'  casting  on  the  sound 
side. 

Clip  and  shave  the  hair  from  the  region  of  the  frontal 
bone  at  that  point  which  the  operator  has  reason  to  believe 
is  nearest  the  center  of  disease.  The  highest  point  at  which 
the  sinus  may  be  trephined  is  indicated  by  F  in  Plate  III. 
The  most  central  portion  of  the  cavity  is  reached  by  trephin- 


Plate  III. 
Trephining  the  Facial  Sinuses. 

F,  highest  point  at  which  an  opening  may  be 
made  into  the  frontal  sinus  without  wounding 
the  cranium  and  brain  ;  N,  opening  into  nasal 
sinus ;  SM,  opening  into  superior  maxillary 
sinus  ;  IM,  opening  into  external  portion  of  in- 
ferior maxillary  sinus  ;  IM',  opening  into  the 
median  portion  of  the  inferior  maxillary  sinus. 


TREPHINING  OF  THE  FRONTAL  SINUSES. 


23 


in^  on  a  level  with  the  inferior  border  of  the  orbital  cavity 
on  the  lines  FE,  Plates  V  and  VI.  Trephining  at  this 
point  gives  the  operator  access  to  the  superior  maxillary 
sinus,  SM,  Plates  IV-VI,  through  the  fenestrum,  FE, 
Plates  V  and  VI.  The  lowest  and  generally  most  essential 
point  for  trephining  is  at  ST,  Plates  IV  and  V,  where  the 
opening  affords  free  drainage  externally  from  the  most  de- 
pendent part  of  the  cavity  and  at  the  same  time  offers 
ample  opportunity  for  securing  dependent  nasal  drainage  by 
breaking  through  the  superior  turbinated  bone  at  ST, 
Plates  IV,  V  and  XI. 

By  consulting  Plates  VII-IX,  it  will  be  seen  that  after 
reaching  the  level  of  the  nasal  septum,  a  trephine  opening 
immediately  against  the  median  line  like  that  at  F,  Plate 
III  would  wound  the  septum  and  superior  turbinated  bone 
and  penetrate  the  nasal  cavity.  Consequently  the  operator 
must  avoid  making  the  trephine  opening  in  this  region  near 
the  median  line,  but  must  keep  i^A  to  2  inches  laterally 
therefrom. 

With  a  heavy  convex  scalpel  make  a  circular  incision  at 
the  desired  point  as  large  as  the  area  of  the  trephine,  directly 
through  the  skin,  subcutem  and  periosteum  down  to  the 
bone  and  remove  in  one  piece  the  entire  mass  of  encircled 
soft  tissues  by  seizing  the  skin  with  a  tenaculum  and  forcibly 
separating  the  periosteum  from  the  bone  with  the  scalpel  or 
bone  chisel.     Control  the  hemorrhage. 

With  the  center-bit  of  the  trephine  extended  place  it  accu- 
rately upon  the  denuded  area  perpendicular  to  the  surface 
of  the  bone  and  grasping  the  handle  firmly  turn  it  to  and 
fro  until  the  bit  has  penetrated  the  bony  plate  and  the  saw 
has  cut  a  distinct  groove  to  serve  as  a  guide  when  the  center- 
bit  should  be  retracted  and  the  operation  continued  until 
the  disc  of  bone  is  detached,  being  careful  to  maintain  the 
trephine  perpendicular  to  the  surface.  The  operation  is 
facilitated  by  grasping  the  shaft  of  the  trephine  between 


Plate  IV. 

Trephining  of  Facial  Sinuses. 

Right  side  of  face,  viewed  laterall}-,  showing  extent  and 
relations  of  the  sinuses.  O,  orbital  cavity  ;  SM,  superior 
maxillary  sinus  ;  IM',  median  portion  of  inferior  maxillary 
sinus  ;  NC,  nerve  conduit  of  superior  maxillary  trunk  of  the 
trifacial  ;  IM,  lateral  portion  of  inferior  maxillary  sinus  ;  F, 
frontal  sinus  ;  ST,  opening  through  superior  turbinated  bone 
for  the  establishment  of  drainage  from  the  frontal  and  superior 
maxillary  sinuses  into  the  nasal  passage  ;  IT,  opening  through 
iuferior  turljinated  bone  for  the  establishment  of  drainage 
from  the  median  portion  of  the  inferior  maxillary  sinus  into 
the  nasal  cavitv. 


TREPHINING  OF  THE  FRONTAL  SINUSES. 


27 


the  thumb  and  fingers  of  one  hand,  constituting  a  support 
in  which  it  may  turn  back  and  forth.  The  pressure  under 
which  the  trephining  is  carried  out  must  not  be  too  great 
or  the  instrument  may  become  wedged  and  broken. 

When  the  bony  plate  which  has  been  isolated  begins  to 
loosen,  remove  the  trephine  and  break,  or  pry  out  the  piece 
of  bone  with  the  bone  gouge  or  chisel.  Smooth  any  uneven 
edges  of  bone  with  a  heavy  scalpel  or  by  re-inserting 
the  trephine  and  using  it  as  a  rasp.  The  abnormal  contents 
of  the  sinus  may  now  escape  through  the  opening  or  be  re- 
moved with  the  curette,  forceps  or  scissors,  and  the  cavity 
irrigated  with  an  antiseptic  fluid. 

Leave  the  trephine  wound  entirely  open  and  irrigate  the 
sinuses  daily  with  antiseptics. 

The  frontal,  being  in  free  communication  below  with  the 
superior  maxillary  sinus,  the  irrigating  fluids  may  fall 
directly  into  the  latter  until  it  becomes  filled.  The  superior 
turbinated  bone  of  the  same  side  forming  the  median  wall 
of  the  frontal  sinus,  it  is  commonly  perforated  by  necrosis, 
in  cases  of  serious  disease  establishing  a  communication  be- 
tween the  frontal  and  nasal  cavities,  through  which  pus 
and  irrigating  fluids  readily  escape  into  the  nostril. 

It  has  been  assumed  that  pus  or  other  contents  in  con- 
siderable quantity  might  pass  from  the  superior  maxillary 
sinus  into  the  nasal  cavity  through  the  normal  communi- 
cating slit  between  the  two  cavities  but  a  careful  study  of 
anatomical  arrangement  of  these  parts,  opposite  N,  Plates 
VII-X,  shows  very  clearly  that  it  is  impossible  as  the 
margins  of  the  slit  acts  as  a  valve  and  closes  it  when  pressure 
is  applied  from  within. 

In  order  to  prevent  the  aspiration  by  the  patient  of  the 
contents  of  the  sinuses,  whether  pus,  blood  or  irrigating 
fluids,  and  to  facilitate  their  escape  from  the  nostril,  any 
irrigation  on  the  recumbent  animal  should  be  carried  out 
with  the  poll  elevated  and  the  head  flexed. 


Plate   V. 

Trephining  of  Facial  Sinuses. 

Oblique  lateral  view  of  the  face  with  the  sinuses  exposed. 
SM,  superior  maxillary  sinus  ;  IM^,  median  portion  of  in- 
ferior maxillary  sinus  ;  NC,  nerve  conduit  of  superior  maxil- 
lar}'  division  of  trifacial  nerve  ;  IM,  lateral  portion  of  inferior 
maxillary  sinus ;  F,  frontal  sinus  ;  FE,  fenestrum  of  com- 
munication between  the  frontal  and  superior  maxillary 
sinuses  ;  ST,  artificial  opening  through  the  superior  turbi- 
nated bone  at  the  lowest  part  of  the  frontal  sinus  establishing 
a  free  communication  with  the  nasal  passage ;  IT,  artificial 
opening  through  the  inferior  turbinated  bone  at  the  bottom 
of  the  median  portion  of  the  inferior  maxillary  sinus,  affording 
drainage  into  the  nasal  passage. 


TREPHINING  OF  THE  FRONTAL  SINUSES. 


31 


By  studying  Plates  IV-X  it  will  be  seen  that  any  collec- 
tion of  pus  or  other  pathologic  contents  in  the  frontal  sinus 
at  F  would  result  in  poor  drainage  so  far  as  may  be  obtained 
by  trephining  through  the  external  wall  only.  The 
drainage,  whether  the  contents  have  formed  within  the 
frontal  sinus  itself,  or  have  entered  it  through  the  fenestrum, 
FE,  Plates  V  and  VI,  from  the  superior  maxillary  sinuses 
should  be  completed  by  making  an  artificial  communication 
through  the  turbinated  bone  between  the  frontal  sinus  and 
the  nasal  fossa  at  ST,  Plates  IV,  V  and  XI.  This  is  to  be 
accomplished  by  breaking  through  the  thin  walls  of  the 
turbinated  bone  by  means  of  a  probe  or  other  suitable  instru- 
ment and  enlarging  the  opening  sufficiently  with  the  probe- 
pointed  bistoury  or  with  the  finger.  In  locating  the  exact 
point  for  making  this  opening  in  the  turbinated  bone  it  is 
advisable  to  pass  a  slightly  curved  heavy  probe,  a  pair  of 
long  curved  uterine  dressing  forceps  or  some  other  slightly 
curved  and  somewhat  rigid  instrument  up  the  nostril  to 
the  operative  region  and  having  an  index  finger  in  the 
sinus  against  the  median  wall,  the  movements  of  the  sound 
can  easily  be  felt  and  the  wall  be  broken  down  either  by 
pushing  the  sound  up  into  the  sinus  or  thrusting  the  finger 
downwards  into  the  nasal  passage. 

In  order  to  prevent  aspiration  of  pus,  blood  or  other  fluids 
after  the  perforation  of  the  highly  vascular  turbinated  bone, 
the  animal  must  be  allowed  to  get  up  immediately  or  if 
under  general  anaesthesia  a  trachea  tube  should  be  inserted 
sufficiently  early  to  avoid  danger. 

Thread  a  long  probe  with  a  heavy  suture  about  75  cm. 
long  and  inserting  it  through  the  trephine  opening  into  the 
nasal  passage  draw  it  out  through  the  nostril  and  removing 
the  probe,  attach  a  strip  of  gauze  75  cm.  long  to  one  end  of 
the  suture,  draw  it  out  through  the  nostril  and  tie  the  ends 
together  on  the  side  of  the  face  to  prevent  dislodgement. 
Retain  the  gauze  in  position  for  about  forty-eight  hours  to 


32 


TREPHININa  S(  PERIOR  MAXILLIARY SINUSES. 


insure  the  permaneucy  of  the  opening  through  the  turbi- 
nated bone.  In  case  of  severe  hemorrhage  the  nasal  and 
sinusal  cavities  may  be  tamponed  for  twenty-four  hours  with 
a  long  strip  of  gauze  which  may  be  secured  if  necessary  by 
suturing  to  the  lips  of  the  trephine  wound.  In  practice  the 
operation  can  be  best  carried  out  generally  with  the  animal 
in  the  standing  position  the  operative  area  being  first 
anaesthetized  by  the  use  of  cocaine  or  by  inducing  artificial 
oedema.  In  the  standing  position  we  largely  avoid  the 
danger  of  aspiration  of  fluids  and  the  hemorrhage  is  greatly 
lessened. 


4.    TREPHINING  THE  SUPERIOR  MAXILLARY  SINUSES. 
Plates  IIl-X. 

Uses.  Empyema,  diseased  teeth,  odontomes  or  other 
tumors. 

Instruments.     Same  as  for  the  frontal  sinuses. 

x\natoniically  there  are  two  maxillarj^  sinuses,  superior, 
SM,  and  inferior,  IM,  Plates  III-X,  having  a  thin  im- 
perforate bony  partition  between  them.  This  partition 
shifts  somewhat  in  position  with  age  and  in  case  of  disease 
undergoes  profound  changes  in  location  and  is  frequently 
totally  obliterated  in  cases  of  empyema,  dental  cysts  and 
other  affections.  If  the  sinusal  partition  be  present,  good 
drainage  of  the  superior  sinus  may  demand  the  surgical 
destruction  of  the  partition  so  that  some  authors  advise 
trephining  directly  upon  the  partition  in  ordei  to  open  the 
two  cavities  simultaneously. 

In  extensive  disease  of  either  sinus  the  partition  between 
the  two  frequently  becomes  obliterated  so  that  there  remains 
but  one  sinus  to  open  ;  in  limited  disease  the  opening  of  both 
cavities  is  ill  advised.  In  extensive  disease  the  existence 
of  a  partition  may  generally  be  ignored   in  operating  and 


TREPHINING  SUPERIOR  MAXILLARY SINCSES. 


33 


the  trephine  opening  be  aimed  at  the  probable  focus  of  the 
malady  and,  should  this  fail  to  reach  the  desired  locality, 
the  proper  location  for  the  opening  may  now  be  determined 
by  digital  or  other  examination  through  the  first  opening. 
A  second  operation  should  then  be  made  to  directly  reach 
the  seat  of  the  affection  and  if  need  be,  yet  a  third  to  secure 
proper  drainage. 

Shave  and  disinfect  as  much  of  the  area  as  may  be  re- 
quired bounded  above  by  the  inferior  border  of  the  orbital 
cavity,  laterally  by  the  zygomatic  ridge,  inferiorly  by  the 
lower  end  of  the  zygoma  and  medianwards  by  the  middle 
line  of  the  face.  Determine  the  proper  point  for  operation 
by  percussion  or  otherwise.  If  it  be  desired  to  enter  the 
superior  maxillary  sinus  only,  SM,  Plates  III-X,  locate  the 
opening  beneath  tlie  orbital  cavity  and  in  front  of  the  zygo- 
matic ridge,  SM,  Plate  III,  or  at  any  point  directly  beneath 
this  to  midway  between  SM  and  IM,  Plate  III,  at  about 
the  level  of  the  dotted  line  IM'. 

The  trephining  is  carried  out  as  described  for  the  frontal 
sinuses  on  page  19.  ilfter  the  trephining  has  been  com- 
pleted remove  any  purulent  collection  or  tumors  or  carry 
out  any  other  necessary  operation  in  the  affected  sinuses 
and  after  cleansing,  if  the  trephine  opening  does  not  insure 
perfect  drainage  of  the  lateral  sac,  either  lower  it  by  cutting 
away  its  Inferior  border  with  the  bone  forceps  or  make  a 
second  trephine  opening  at  the  necessary  point. 

Since  empyema  of  the  superior  maxillary  sinuses  is  due  in 
the  vast  majority  of  ca.ses  to  infection  derived  from  diseased 
teeth  or  dental  alveoli  it  is  es.sential  after  the  sinus  has  been 
opened  that  the  operator  search  carefully  and  minutely  over 
the  alveoli  of  the  molars  for  naked,  eroded  tooth  fangs  or 
for  fastulae  leading  down  into  the  dental  alveoli.  If  dental 
disease  is  recognized  the  trephining  of  the  sinus  is  to  be 
supplemented  by  repulsion  of  the  offending  tooth  as 
described  on  page  8. 
3 


Plate    VI 

Trephining  of  Facial  Sinuses. 

Frontal  view  of  right  side  of  face  with  sinuses 
exposed.  SM,  superior  maxillary  sinus ;  IM^, 
median  portion  of  inferior  maxillary  sinus  ;  IM, 
lateral  portion  of  inferior  maxillary  sinus  ;  F, 
frontal  sinus  ;  FE,  communication  between  the 
frontal  and  superior  maxillary  sinuses. 


SM 


TREPHINING  SUPERIOR  MA  NIL  LARY  SINUSES. 


37 


Under  the  influence  of  disease  the  sinuses  may  extend  far 
beyond  their  normal  location  or  may  contract  or  become 
largely  obliterated  by  being  filled  with  new  bone  or  soft 
tissue.  The  median  portion  of  the  superior  maxillary  sinus 
on  the  inner  side  of  the  bony  conduit  of  the  trifacial  nerve, 
NF,  Plates  IV-X,  can  not  always  be  completely  drained 
through  the  opening  SM,  Plate  III,  and  provision  for  this 
must  then  be  made  by  trephining  into  the  lower  part  of  the 
frontal  sinus  and  thence  breaking  through  the  superior 
turbinated  bone,  ST,  Plates  IV-V,  into  the  nasal  passage 
or  at  times  it  may  be  feasible  to  break  through  the  inner 
wall  of  the  superior  maxillary  sinus  on  the  median  side  of 
the  nerve  conduit  into  the  nasal  cavity.  If  the  inferior 
maxillary  sinus  is  also  involved  good  nasal  drainage 
may  be  had  by  breaking  down  the  inter-sinusal  partition 
and  then  penetrating  the  inferior  turbinated  bone  at  IT, 
Plates  IV-V,  and  inserting  through  this  opening  a  long  and 
thick  strip  of  gauze  which  is  brought  out  through  the  nostril 
and  the  ends  tied  together  on  the  side  of  the  face  to  prevent 
displacement.  Retain  this  in  position,  renewing  daily  until 
the  permanency  of  the  opening  is  assured. 

It  generally  occurs  in  extensive  empyema  of  the  sinuses 
that  an  opening  in  the  turbinated  bone  takes  place  by 
necrosis  and  in  some  cases  affords  the  desired  drainage 
while  in  the  majority  the  pathologic  opening  is  so  placed 
that  it  is  incomplete. 

Leave  all  wounds  entirely  open  and  irrigate  daily  with 
antiseptic  solutions. 

Dangers.  Care  must  be  exercised  to  not  injure  the 
superior  maxillary  division  of  the  trifacial  nerve,  NF, 
Plates  IV-X,  either  in  trephining  or  after  the  sinuses  have 
been  opened.  The  bony  conduit  of  this  nerve  is  in  rare 
cases  entirely  resorbed  by  pressure  from  dental  cysts  or 
other  causes,  leaving  it  stretched  across  the  cavity  as  a  white 
nacrous  cord,  intensely  sensitive.     Any  injurj^  to  this  nerve 


Plate   VII. 

Trephining  of  Facial  Sinuses. 

Cross  section  of  the  right  half  of  the  head  of 
a  horse  at  the  posterior  border  of  the  last  molar. 
F,  frontal  sinus  ;  IM,  lateral  portion  of  inferior 
maxillary  sinus  at  extreme  posterior  or  superior 
part  ;  IM^,  median  portion  do,;  N,  nasal  cham- 
ber opposite  the  communication  between  it  and 
the  superior  maxillary  sinus  ;  NF,  conduit  of 
superior  maxillary  branch  of  the  trifacial  nerve  ; 
vSM,  superior  maxillary  sinus  ;  M',  fragment  of 
last  molar. 


IM- 


TREPHINING  INFERIOR  MAXILLAR  Y  SINUS.         4 1 

causes  intense  pain  and  renders  the  animal  very  resistant  to 
the  necessary  manipulations  in  the  after  care  of  the  wound 
and  may  leave  the  patient  pernamently  nervous  about  the 
handling  of  its  face. 

Hemorrhage  is  generally  not  severe  and  may  occur  from 
the  skin,  where  it  may  be  readily  controlled  by  compression 
or  ligation  ;  from  the  intra-osseous  vessels,  where  it  may 
be  checked  by  pressure  with  absorbent  cotton,  by  pushing 
a  small  portion  of  cotton  into  the  channel  of  the  vessel 
with  a  needle  or  tenaculum  or  by  plugging  the  vessel  with 
a  conical  piece  of  wood  ;  from  the  wounded  turbinated 
bones  where  it  may  be  stopped  by  packing  with  gauze. 
These  tampons  should  be  removed  after  twenty-four  hours. 


5.     TREPHINING  THE  INFERIOR  MAXILLARY  SINUS. 
Plates  III  XI. 

Uses  and  Instruments.     Same  as  in  the  preceding. 

Anatomical  Outline.  The  inferior  maxillary  sinus  is 
an  exceedingly  irregular  cavity,  differing  in  details  of  form 
and  extent  in  individuals  and  at  various  ages.  As  shown 
in  the  illustrations  its  disposition  might  be  compared  to  a 
pair  of  saddle  bags  hanging  over  the  nerve  conduit,  the 
lateral  and  median  chambers  not  very  unlike  in  extent. 
As  suggested  in  Plates  IV-V,  the  floor  of  the  lateral  cavity 
is  broken  up  by  irregular  bony  septa,  which  in  some  cases 
cut  the  sinus  up  into  quite  separate  cavities.  Sometimes  it 
extends  downwards  barely  below  the  end  of  the  zygoma, 
at  other  times  it  reached  down  below  the  infra-orbital 
foramen.  There  is  hence  no  rule  by  which  the  operator 
may  at  all  times  make  his  opening  precisely  at  the  lower 
extremity  of  the  sinus. 

Technic.  The  general  technic  is  the  same  as  for  the 
frontal   and   superior   maxillary  sinuses,   but  two  trephine 


Plate    VIII. 

Trephining  the  Facial  Sinuses. 

Cross  section  of  the  left  side  of  the  head  of  an 
aged  horse  at  the  second  molar,  seen  from  the 
front.  F,  frontal  sinus  ;  N,  nasal  sinus,  oppo- 
site the  communication  between  the  nasal  and 
inferior  maxillary  sinuses ;  IM,  lateral  portion 
of  inferior  maxillary  sinus  ;  IM^,  median  portion 
of  inferior  maxillary  sinus  ;  SM,  superior  max- 
illary sinus  ;  NF,  superior  maxillary  division  of 
trifacial  nerve  in  its  bony  conduit ;  SZ,  subzygo- 
matic  artery  ;  P,  palatine  artery  ;  M2,  second 
molar. 


TREPHINING  THE  NASAE  FOSSAE. 


45 


openings  should  always  be  made.  The  first  opening  should 
be  made  close  against  the  median  side  of  the  zygoma  near 
its  lower  or  nasal  extremity,  Plate  III,  IM,  and  the  inferior 
border  lowered  sufficiently  with  the  bone  forceps  to  provide 
thorough  drainage  for  the  lateral  compartment  of  the  sinus. 
The  second  opening  is  to  be  made  on  the  median  side  of 
the  nerve  conduit,  NC,  Plates  IV-V  as  indicated  at  IM'  in 
Plate  III.  The  location  may  be  accurately  determined  by 
palpating  with  the  index  finger  through  the  first  opening 
at  IM,  Plate  III.  This  compartment  can  not  be  well  drained 
upon  the  face  through  either  of  the  trephine  openings  and 
a  third  opening,  penetrating  the  inferior  turbinated  bone  at 
IT,  Plates  IV-V,  is  essential  to  ideal  results  by  affording 
free  drainage  into  the  nasal  chamber.  The  opening  through 
the  inferior  turbine  is  made  in  the  same  manner  as  described 
for  the  opening  through  the  superior  turbine  from  the 
frontal.  Thorough  search  should  be  made  throughout  the 
sinus  for  the  causes  of  disease,  teeth,  etc.,  these  removed  and 
followed  by  after  treatment  the  same  as  advised  for  the  two 
preceding  operations. 


6.    TREPHINING  THE  NASAL  FOSSAE. 
Plates   VII-X. 

Uses.  Operations  upon  the  septum  nasi,  or  the  tur- 
binated bones,  or  the  removal  of  tumors  or  foreign  bodies 
from  the  nasal  passages. 

Instruments.  Same  as  for  the  frontal  sinuses  (page 
19). 

Technic.  The  trephining,  N,  Plate  III,  is  carried  out 
by  the  method  described  above,  in  the  nasal  bone,  close  by 
the  median  line  of  the  face  and  according  to  indications  at 
any  point  from  a  level  of  the  dotted  line,  SM,  Plate  III,  to 
the  juncture  between  the  na.sal  and  pre-maxillary  bones 
near  the  upper  extremity  of  the  false  nostril. 


Plate  IX. 

Trephining  the  Facial  Sinuses. 

Cross  section  obliquely  downwards  and  back- 
wards through  the  right  half  of  the  head  of  a 
two-year  old  colt  at  the  first  molar.  F,  frontal 
sinus  ;  N,  nasal  passage  at  point  of  communica- 
tion with  the  inferior  maxillary  sinus,  IM  ;  IM^, 
median  portion  of  inferior  maxillary  sinus  ;  SM, 
extreme  lower  end  of  superior  maxillary  sinus 
opened;  Mi,  first  molar;  M2,  second  molar; 
P,  palatine  artery  ;  SZ,  sub-zygomatic  artery. 


-Ma 


TREPHINING  THE  NASAL  EOSSAE. 


49 


A  study  of  Plates  VII-X  will  show  that  the  trephining 
of  these  cavities  requires  great  care  in  order  to  avoid  wound- 
ing either  the  highly  vascular  septum  nasi  or  even  more 
vascular  turbinated  bones.  The  operation  should  be  im- 
mediately against  the  septum  since  otherwise  the  superior 
turbinated  bone  may  be  wounded  or  an  important  intra- 
osseous artery  in  the  nasal  bone,  just  above  its  union  with 
the  superior  turbinated,  as  shown  in  Plate  IX,  may  be 
severed. 

If  the  turbinated  bone  is  penetrated  the  frontal,  and 
through  it,  the  superior  maxillary  sinus  is  opened  and  ex- 
posed to  infection  with  all  its  consequences.  Special  care 
is  accordingly  necessary  that  the  trephining  should  not  be 
carried  too  deeply,  that  the  bone  be  barely  penetrated,  and 
that  the  osseous  disc  be  carefully  removed  in  order  to  avoid 
the  wounding  of  the  turbinated  bone,  which  Hes  in  close 
proximity  to  the  nasal  bone.  The  operative  area  is  narrow 
and  the  trephine  used  should  not  exceed  2  cm.  in  diameter. 

Whenever  possible  the  operation  should  be  carried  out 
on  the  standing  animal  which  decreases  the  hemorrhage 
and  the  danger  from  aspiration  of  fluids.  The  hemorrhage 
may  be  further  controlled  in  operations  upon  the  septum 
nasi  and  turbinated  bones  by  spraying  the  parts  with 
adrenaline  chloride  and  cocaine.  Even  in  the  standing 
animal,  if  extensive  operations  are  to  be  carried  out  on  the 
very  vascular  septum  nasi  or  on  the  turbine,  it  is  advisable 
to  preform  trachetomy  before  trephining,  and  retain  the 
trachea  tube  in  position  until  all  danger  has  passed.  When 
the  animal  is  confined  in  the  recumbent  position  the 
patient's  safety  demands  that  tracheotomy  be  performed  in 
almost  all  cases  before  any  operation  is  begun  upon  the 
septum  nasi  or  turbinated  bones.  After  tracheotomy, 
anaesthesia  may  be  maintained  by  means  of  an  ordinary 
funnel  with  its  tube  bent  at  right  angles  and  inserted  into 

4 


Plate  X. 

Trephining  of  Facial  Sinuses. 

Cross  section  of  the  left  side  of  the  head 
anterior  to  the  last  molar,  and  through  the 
widest  part  of  the  inferior  maxillar\'  sinus.  M^, 
last  superior  molar ;  SINI,  superior  maxillary 
sinus  at  its  antero-iuferior  extremity  ;  IM,  in- 
ferior maxillary  sinus,  lateral  portion  ;  IM^,  do. 
median  portion ;  N,  nasal  fossa  ;  S,  sound 
lodged  in  lachrymal  duct  ;  NF,  trifacial  nerve ; 
F,  frontal  sinus. 


IM- 


—  F 


-NF 
-  - 1 M 


u. 


—  SM 


—  M 


POLL  E]'IL  OPERATION. 


53 


the  trachea  tube  while  the  chloroform  is  dropped  on  a  towel 
spread  over  its  mouth.  After  completing  any  required 
operation  upon  the  septum,  turbinated  bones  or  other  parts, 
hemorrhage  may  be  controlled  by  packing  one  or  both  nasal 
fossae  with  single  strips  of  gauze  of  sufficient  size  and 
carefully  securing  them  by  sutures  to  the  sides  of  the 
trephine  wound  or  otherwise. 


7.     POLL  EVIL  OPERATION. 
Plate  XL 

Instruments.  Clipping  shears,  razor,  sharp  scalpels,  one 
dozen  compression  artery  forceps,  probe-pointed  bistoury, 
probe,  Luer's  bone  forceps,  bone  gouge,  curette,  suture  and 
dressing  material. 

Technic.  Clip  the  foretop  and  mane  and  shave  the 
forehead  and  the  top  of  the  neck  back  to  a  distance  of  8  or 
lo  cm.  or  as  much  farther  as  may  be  required  to  pass  beyond 
and  behind  the  supposed  extension  of  disease,  and  disinfect 
the  area.  Confine  the  animal  in  lateral  decubitis  preferably 
upon  the  operating  table,  place  under  complete  anaesthesia 
and  remove  the  halter  or  other  headgear. 

With  sharp  scalpel  make  a  longitudinal  incision  on  the 
median  line  of  the  head  and  neck  beginning  at  a  point 
presumably  posterior  to  the  diseased  area  and  carrying  it 
over  the  poll  down  onto  the  forehead  for  a  distance  of  4  or 
5  cm.  below  the  foretop.  Continue  this  incision  through 
the  skin,  the  subcutem,  the  adipose  tissue,  AT,  Plate  XI, 
and  either  through,  or  passing  around  alongside  the  neck 
ligament,  LN,  into  the  diseased  area  beneath  the  latter. 
Dissect  the  ligamentum  nuchse  away  from  the  adjoining 
tissues  as  far  back  as  diseased,  divide  it  obliquely  upward 
and  backward  as  indicated  at  AA,  and  detach  anteriorly 
from  the  base  of  the  occiput.     Be  careful  to  remove  every 


<   o 


cs    n    3 
■S  -S  -5 

O     4J     tn 


-l-> 

lU 

o 

lU 

'^ 

X 

o 

Ph 

1 

o 

■& 

5 

tc 

_o 

'S    o 


s"  1^   3 


POLL  EVIL  OPERATION.  57 

portion  of  the  ligament  in  the  area  indicated  and  all  calca- 
reous deposits  or  other  diseased  tissues. 

With  lyuer's  forceps  groove  a  channel  about  2  cm.  wide 
from  behind  to  before  directly  upon  the  median  line,  through 
the  occipital  protuberance  to  the  depth  of  about  2  cm.  mak- 
ing the  bottom  as  near  as  possible  on  a  level  with  the  wound 
in  the  soft  tissues  as  indicated  by  the  dotted  line,  AA. 
Using  Luer's  forceps  as  a  curette  detach  all  vestiges  of  the 
neck  ligament  from  the  base  of  the  occiput  and  leave  the 
bone  bare  and  smooth.  If  the  Luer  or  ronguer  forceps  are 
not  available  the  grooving  of  the  occiput  may  be  accom- 
plished with  a  strong  curved  bone  gouge.  Or  the  grooving 
of  the  occiput  and  curetting  away  of  the  attachments  of  the 
neck  ligament  to  the  base  of  the  occiput  may  be  very 
effectually  accomplished  with  a  hoof  knife.  Be  careful  to 
avoid  penetrating  the  cranial  cavity  or  the  occipito-atloid 
articidation .  If  the  operator  is  not  perfectly  clear  regarding 
the  anatomy  of  the  parts  he  would  do  well  to  have  before 
him  a  sagittal  section  of  the  head  of  a  horse  which  may 
serve  as  a  guide.  In  curetting  the  ligamentous  attachments 
from  the  occiput  the  operator  should  keep  the  index  finger 
of  the  left  hand  at  the  bottom  of  the  wound,  against  the 
occipito-atloid  ligament  in  order  to  protect  it  from  injury. 
The  operation  is  rendered  safer  also  by  rigid  control  of  the 
hemorrhage  to  which  end  he  needs  an  ample  number  of 
compression  artery  forceps. 

Control  the  hemorrhage,  cleanse  and  disinfect  the  wound, 
pack  with  iodoform  gauze  and  suture  for  its  entire  length 
except  the  anterior  part,  where  the  tampon  should  slightly 
protrude,  and  dust  the  margin  of  the  wound  with  iodoform 
and  tannin.  Remove  the  tampon  after  foity-eight  hours 
and  dress  antiseptically  daily.  The  sutures  may  or  may 
not  be  removed  according  to  conditions.  In  carrying  out 
this  operation  our  chief  aim  should  be  to  remove  all  diseased 
parts,  to  afford  perfect  drainage  anteriorly,  to  secure  and 
maintain  antisepsis,  and  to  keep  the  wound  directly  on  the 
median  line  from  which  no  visible  scar  will  result. 


Plate  XII. 
Ligation  of  the  Parotid  Duct. 

Fig.  I.  Segment  of  the  left  ramus  of  the  in- 
ferior maxiHa  of  the  horse  seen  from  the  right 
and  beneath,  sp,  usual  operative  field  ;  a,  ex- 
ternal maxillary  artery  ;  z>,  external  maxillary 
vein  ;  st,  si,  parotid  duct. 

Fig.  2.  Life  size  of  operation  field  on  external 
side  of  maxilla  ;  a,  external  maxillary  artery  ;  z\ 
external  maxillary  vein  ;  .s7,  parotid  duct  ;  ;;/. 
masseter  muscle. 


Fig. 


LIGATION  OF  THE  PAROTID  DUCT.  6 1 

8.    LIGATION  OF  THE  PAROTID  DUCT. 
Plate  XII. 

Objects.  The  destruction  of  the  parotid  gland  in  case  of 
fistula  from  wounds  or  abscesses. 

Instruments.  Razor,  convex  scalpel,  straight  probe- 
pointed  scalpel,  tenaculum  forceps,  ligation  forceps,  tenacula, 
needle  holder,  probe,  suture  and  dressing  material. 

Technic.  In  case  of  salivar}'  fistula  insert  a  probe 
toward  the  gland  through  the  fistula  into  the  duct  and  with 
a  sharp  scalpel  lay  the  duct  free  for  a  distance  of  from  i  to 
2  cm.  on  the  glandular  side  of  the  fistulous  opening.  If  the 
fistula  has  its  location  on  the  side  of  the  cheek,  cast  the 
horse  and  shave  and  disinfect  the  region  on  the  inferior 
maxilla  where  the  artery,  vein  and  parotid  duct  turn  around 
its  inferior  border.  When  the  operator  glides  his  finger 
over  the  vascular  region  forward  and  backward  there  is  felt 
a  resistant  cord,  the  pulsating  external  maxillary  artery 
about  3  mm.  in  diameter.  Between  this  and  the  oral  border 
of  the  masseter  muscle  make  an  incision  about  4  cm.  long 
parallel  to  the  artery  through  the  skin  and  skin  muscle. 
Pick  up  the  loose  connective  tissue  with  a  pair  of  forceps 
and  excise  it.  Immediately  behind  the  external  maxillary 
artery,  a,  Figs,  i  and  2,  Plate  XII,  is  the  external  maxil- 
lary vein,  V,  and  behind  this  and  immediately  at  the  border 
of  the  masseter  muscle  lies  the  parotid  duct,  si. 

In  case  of  salivary  calculi  which  cannot  be  removed 
through  the  mouth  or  of  cystic  dilation  of  the  parotid  duct, 
make  the  cutaneous  incision  at  the  affected  point,  open  the 
canal,  and  after  the  removal  of  the  calculus,  etc.,  close  the 
duct  wound  by  means  of  intestinal  sutures  in  such  a  way 
that  the  external  surfaces  of  the  lips  of  the  wound  in  the 
wall  of  the  duct  are  brought  in  contact,  or  ligate  the  duct 
on  the  proximal  side  of  the  point  of  operation  and  destroy 
the  gland. 


62  ENTROPIUM  OPERATION. 

Ligation  of  the  duct  is  accomplished  by  passing  a  strong 
silk  thread  beneath  the  duct  by  means  of  a  curved  aneurism 
needle,  carrying  the  ligature  around  the  duct  and  tying 
with  a  surgeon's  knot.  The  parotid  duct  \wa.y  also  be 
previously  split  and  an  internal  wound  made  at  the  point  of 
ligation.  Close  the  skin  wound  by  means  of  a  continuous 
suture  and  cover  the  operative  surface  with  iodoform 
collodion  or  with  wound  gelatine. 


9.     ENTROPIUM  OPERATION. 

Instruments.  Razor,  scissors,  convex  scalpel,  tenaculum 
and  ligation  forceps,  tenacula,  needle  holder,  needles,  thread, 
absorbent  cotton. 

Technic.  Quiet  adult  horses  may  be  operated  upon  in 
the  standing  position  with  the  aid  of  local  anaesthesia,  other 
horses  and  small  animals  should  be  secured  in  lateral  re- 


FlG.     I. 
Eutropium  operation  on  the  superior  and  inferior  eyelids  of  the  dog. 

cumbency  preferably  upon  the  operating  table.  Shave  and 
disinfect  the  skin  of  the  inverted  eyelid.  Grasp  the  skin  of 
the  eyelid  midway  between  the  inner  and  outer  canthi 
with  the  forceps  and  elevate  a  skin  fold  parallel  with  the 
border  of  the  eyelid  to  such  a  height  that  the  inverted 
member  assumes  its  normal  position.     Pass  a  finger  into  the 


STAPHYLOrOMY. 


63 


<:onjiinctival  sac  to  make  sure  that  the  conjunctiva  is  not 
drawn  into  the  skin  fold.  Clip  the  fold  off  with  the  scissors 
immediately  below  the  forceps,  removing  an  oblong  piece. 
Between  the  border  of  the  eyelid  and  that  of  the  wound 
the  skin  should  be  left  intact  for  at  least  .5  cm.  Ligate  or 
compress  any  bleeding  vessels  and  close  the  wound  by  means 
of  interrupted  sutures.  The  wound  may  be  covered  with 
iodoform  collodion  or  wound  gelatine  or  dusted  over  with 
iodoform-tannin.  It  is  usually  unnecessary  and  inadvisable 
to  cover  the  parts  with  hood  or  other  appliance  since  so  long 
as  the  wound  is  healing  properly  the  animal  will  not  disturb 
it. 


10.     STAPHYLOTOMY. 


Object.  An  operation  devised  by  Dr.  M.  H.  McKillip 
for  making  a  manual  exploration  of  the  Eustachian  tubes, 
guttural  pouches,  larynx,  pharynx  and  posterior  nares  ;  and 
for  operations  upon  the.se  structures.  The  form  and  extent 
of  the  soft  palate  of  the  horse  is  such  as  to  render  it  ex- 
tremely difficult  to  make  a  manual  exploration  of  the  parts 
above  and  behind  it,  and  impossible  to  make  a  visual  ex- 
amination except  with  the  aid  of  the  expensive  and  compli- 
cated rhino-laryngoscope,  which  only  aids  in  diagnosis  while 
staphylotomy  combines  with  this  operative  advantages,  per- 
mitting the  free  introduction  of  the  hand  into  the  laryngo- 
pharyngeal region. 

Instruments.  Mouth  speculum,  short  curved  probe- 
pointed  bistoury  with  a  ring  to  fit  the  middle  finger. 

Technic.  Cast  the  patient  or  secure  on  the  operating 
table  in  lateral  recumbency  and  turn  the  nose  upward. 
Adjust  the  mouth  speculum  and  open  the  mouth  as  wide  as 
possible  ;  draw  the  tongue  well  out  with  the  left  hand  while 
the  right  carrying  the  knife  on  the  middle  finger  is  passed 


64 


TRIFACIAL  NEUROTOMY. 


carefully  through  the  fauces  until  it  hooks  over  the  posterior 
border  of  the  soft  palate.  The  knife  is  then  gently  drawn 
forward  making  an  incision  along  the  median  line  of  the 
soft  palate  from  its  posterior,  free  border  to  its  attachment 
on  the  palatine  bone.  The  hand  is  then  withdrawn  and  the 
speculum  removed  for  a  few  minutes  to  permit  the  patient  to 
rid  its  pharynx  of  any  blood  clots  or  mucus  that  may  have 
accumulated.  Readjusting  the  speculum  as  before,  the 
right  hand  is  again  passed  through  the  fauces  and  now  that 
the  palate  is  divided  a  manual  exploration  may  perfectly^ 
reveal  the  presence  of  any  abnormality  in  the  region. 


11.    TRIFACIAL  NEUROTOMY. 

Plate  XIII. 

Object.     The  relief  of  involuntary  shaking  of  the  head- 
Instruments.     Razor,  scissors,  convex  scalpel,  tenacula, 
aneurism  needle,  compression  artery  forceps,  needles,  thread, 
absorbent  cotton,  a  strong  piece  of  muslin  12  cm.  square. 

Technic.  Secure  in  lateral  recumbency,  preferably  upon 
the  operating  table,  and  produce  complete  anaesthesia.  Re- 
move the  halter,  bridle,  or  other  headgear.  Shave  and 
disinfect  an  area  8  to  10  cm.  square  over  the  infra- orbital, 
foramen.  Locate  by  touch  the  infra-orbital  foramen,  lOF, 
Plate  XIII,  below  the  levator  labii  superiorisproprius  muscle 
and  displace  this  slightly  upward  toward  the  median  line  of 
the  uo.se  until  the  foramen  can  be  clearly  felt  below  the 
muscle.  With  the  scalpel  begin  an  incision  somewhat 
superior  to  the  foramen  and  near  its  nasal  border  and  make 
a  wound  downward  and  forward  in  the  direction  of  the 
commisure  of  the  lips  about  5  cm.  long  through  the  skin, 
muscle  and  connective  tissue  down  to  the  nerve  and  control 
hemorrhage  with  the  greatest  care.  If  the  larger  branches- 
of  the  glosso-facial  vessels  are  severed  they  should  be  ligated 


TRIFACIAL  NEUROTOMY 


65 


or  twisted.  It  is  even  better  to  ligate  or  compress  these 
vessels  prior  to  severing  them. 

Hold  the  lips  of  the  wound  apart  with  two  tenaciila  or  by 
placing  a  strong  suture  through  each  wound  margin  and 
through  the  skin  at  a  point  6  to  8  cm.  distant  and  tying  the 
sutures  tightly,  dilate  the  wound  thoroughly  and  dissect 
away  the  connective  tissue  from  the  nerve  until  every  part 
of  it  is  clearly  in  view.  Pass  an  aneurism  needle  beneath 
the  nerve  trunk  and  Hfting  it  from  the  bone  make  a  search 
for  a  small  artery  which  usually  passes  along  beneath  it 
through  the  foramen  and  if  this  can  be  found  either  ligate  it 
immediately  at  its  point  of  emergence  and  again  5  cm. 
lower  down  and  divide  between  the  two  ligatures  or 
separating  it  from  the  nerve  protect  carefully  against  injury. 
With  a  probe-pointed  bistoury  or  scissors  sever  the  nerve  at 
the  foramen  and  grasping  the  distal  end  dissect  away  about 
5  cm.  of  the  trunk  and  excise.  Be  very  careful  to  include 
all  branches  and  especially  one  or  two  superior  or  dorsal 
twigs  which  are  directed  upward  just  as  they  emerge  from 
the  foramen.  After  the  hemorrhage  has  been  brought  under 
complete  control  and  all  blood  clots  have  been  removed 
cleanse  the  wound  carefully,  dust  over  with  iodoform  and 
close  with  continuous  sutures. 

In  order  to  protect  this  first  wound  during  the  operation 
upon  the  other  side  take  the  piece  of  muslin  mentioned 
among  the  needs  for  the  operation,  and  folding  it  several 
times  in  a  square,  place  it  over  the  wound  and  suture  it 
firmly  at  each  corner  to  the  skin.  Turn  the  animal  to  the 
opposite  side  and  repeat  the  operation  on  the  other  nerve 
except  the  application  of  the  square  piece  of  muslin  which 
is  here  unnecessary.  If  circumstances  will  at  all  permit  it 
is  far  safer  to  operate  upon  only  one  side  first,  allowing  this 
to  heal  and  then  operate  upon  the  other  side. 

As  soon  as  the  animal  stands,  remove  the  protective  piece 
of  muslin  from  thp  first  wound,  disinfect  both  wounds,  dust 
5 


Plate  XIII. 

Trifacial  Neurotomy. 

LL,  levator  labii  superioris  proprii  muscle ; 
lOF,  infra-orbital  foramen  ;  NF,  superior  max- 
illary division  of  the  trifacial  nerve. 


LL- 
lOF- 
NF— 


TRIFACIAL  NEUROTOMY.  69 

them  over  with  iodoform  and  tannin  or  cover  with  wound 
gelatine  and  leave  undisturbed  to  heal  by  primary  union. 
Avoid  halter,  bridle  or  other  fixtures  which  might  injure 
the  wounds  after  the  operation. 

In  some  cases  the  operation  may  be  performed  upon  the 
standing  animal  under  local  anaesthesia  and  whenever  this 
is  possible  it  is  greatly  to  be  preferred  since  the  hemorrhage 
is  far  lessened  and  the  danger  from  sepsis  reduced,  but  with 
most  affected  animals  the  standing  operation  is  impractic- 
able. 

Dangers.  The  chief  danger  in  the  operation  is  from  in- 
fection, which  sets  up  a  severe  neuritis  in  the  proximal  end 
of  the  nerve,  aggravates  the  symptoms  and  causes  much 
suffering.  In  order  to  prevent  infection  the  aseptic  precau- 
tions need  be  unusually  strict  in  every  detail  and  the  anaes- 
thesia profound.  Carefully  avoid  wounding  the  neighbor- 
ing vessels  and  control  completely  any  hemorrhage  that 
occurs  in  order  to  avoid  a  hematom  in  the  wound,  which 
always  invites  infection. 

Literature.  Involuntary  twitching  of  the  head  relieved 
by  trifacial  neurectomy.  W.  L.  Williams,  Jour.  Comp. 
Med.  and  V.  A.,  vol.  XVIII,  p.  426.  Involuntary  shaking 
of  the  head  and  its  treatment  by  trifacial  neurectomy,  do. 
Am.  Vet.  Rev.,  vol.  XXIII,  p.  321  and  CEst.  Monatsch. 
Thierheilkunde,  Bd.  XXIV,  s.  211. 


II.     OPERATIONS  ON  THE  NECK. 

12.    OPENING  OF  THE  GUTTURAL  POUCHES. 

Plate  XIV. 

Instruments.  Razor,  Scissors,  convex  sharp-pointed 
and  straight  probe-pointed  scalpels,  artery  forceps,  tenacula, 
probe,  trocar,  curette,  drainage  tubing,  suture  and  dressing 
material. 

Technic.  I.  Viborg^ s  method.  The  operation  is  possible 
on  the  standing  animal,  but  generally  the  patient  must  be 
cast  or  placed  on  the  operating  table  and  secured  in  lateral 
decubitis  with  the  head  extended.  B}^  extending  the  head 
and  compressing  the  jugular  vein  there  is  brought  out  the 
triangle  immediately  behind  the  posterior  border  of  the  in- 
ferior maxilla  and  below  the  parotid  gland  comprised  be- 
tween the  posterior  angle  of  the  inferior  maxilla,  the 
terminal  tendon  of  the  sterno-maxillaris  muscle  and  the 
external  maxillary  vein. 

In  this  so-called  Viborg's  triangle  after  the  removal  of 
the  hair  and  the  disinfection  of  the  skin  which  is  maintained 
stretched,  make  a  5  cm.  long  incision  through  the  skin  and 
skin  muscle  immediately  beneath  the  aforementioned  tendon 
and  parallel  to  it.  In  case  of  pronounced  swelling  in 
Viborg's  triangle  the  operator  must  determine  the  location 
for  the  incision  by  the  position  of  the  sterno-maxillaris 
muscle.  The  skin,  subcutem  and  cervical  fascia  having 
been  incised  to  a  sufficient  extent,  force  a  passage  with  the 
finger  or  with  closed  probe  pointed  scissors  or  other  blunt 
instrument  through  the  loose  connective  tissue  on  the 
median  side  of  the  parotid  gland,  to  the  guttural  pouch  and 
penetrate  it  at  its  lowest  point  with  the  finger  or  trocar. 
In  order  to  open  the  empty  guttural  pouch  as  an  exercise 
operation  it  is  desirable  to  grasp  a  portion  of  its  wall  by 
means  of  forceps.     Through  the  operative  wound  a  drainage 


OPENING  OF  THE  GUTTCRAL  POUCHES. 


71 


tube  can  be  introduced  into  the  pouch,  and  fixed  in  position 
by  sutures.  The  opening  can  be  enlarged  in  an  antero- 
posterior direction  to  the  extent  of  5  to  8  cm.  or  large 
enough  to  admit  the  operator's  hand.  Through  this 
enlarged  wound,  the  operator  may  palpate  the  Eustachian 
tube  and  other  portions  of  the  interior  of  the  pouch  and 
perform  desired  operations. 

A  far  more  common  operation  in  veterinary  practice 
than  the  opening  of  the  guttural  pouches,  is  the  opening  of 
strangles  abscesses  of  the  sub-parotid  lymph  glands,  lying 
between  the  inner  face  of  the  parotid  gland  and  the  external 
face  of  the  guttural  pouch.  The  operation  here  used  is  the 
same  as  Viborg's  for  the  guttural  pouch  but  does  not 
penetrate  that  cavity  because  the  inner  wall  of  the  abscess 
has  pushed  the  external  wall  of  the  pouch  inward  so  that 
the  former  largely  occupies  the  usual  location  of  the  latter. 
The  dyspnoea  generally  prohibits  casting  the  animal  and 
necessitates  operating  in  the  standing  position.  In  some 
cases  the  dyspnoea  is  so  severe  as  to  demand  tracheotomy 
before  the  opening  of  the  abscess  can  be  undertaken  because 
the  excitement  aggravates  the  difficult  respiration  to  the 
point  of  suffocation. 

II.  ChaberV s  metJiod.  Secure  the  horse  in  the  lateral  re- 
cumbent position,  remove  the  hair  and  disinfect  the  skin 
beneath  the  wing  of  the  atlas.  Make  an  incision  about  i; 
cm.  in  front  of  the  lower  half  of  the  wing  of  the  atlas  audi 
parallel  to  it,  about  6  cm.  long  extending  through  the  skin: 
and  skin  muscle  down  to  the  parotid  gland.  The  incisioni 
is  facilitated  by  rendering  the  skin  tense  with  the  left  hand! 
and  care  is  to  be  taken  not  to  wound  the  auricular  nerve- 
which  passes  directly  along  the  atlas.  Then  draw  backward 
the  posterior  lip  of  the  wound  and  separate  with  blunt  in- 
struments the  posterior  border  of  the  parotid  gland  from 
the  alias,  to  which  it  is  bound  by  loose  connective  tissue, 
and  draw  it  forward  with  tenacula.     At  the  bottom  of  the 


Plate  XIV. 

Opening  of  the  Guttural  Pouches  { Hyoyertebrotomy) 
According  to   Viborg  and  Chabert. 

Head  and  neck  of  recumbent  horse  viewed 
from  the  side,  sm,  stylo  maxillaris^niuscle  ;  />, 
parotid  gland  ;  /,  guttural  pouch  ;  k,  larynx  ; 
st,  sterno-maxillaris  muscle ;  r,  rectus  capitus 
anticus  major  muscle  ;  c,  external  carotid  artery  ; 
e,  external  maxillary  artery  ;  /',  internal  maxil- 
lary artery ;  v,  external  maxillar}-  vein  ;  s, 
probe  ;  a,  wing  of  atlas. 


OPENING  OF  THE  UrTTCRAL  POUCHES.  75 

opening  thus  formed  there  is  seen  the  stylo-maxillaris 
muscle,  sm,  Plate  XIV,  lying  against  the  median  side  of 
the  parotid  gland  covered  only  by  the  aponeurosis  of  the 
mastoido-humeralis  muscle.  With  the  handle  of  the  scalpel 
inclined  toward  the  wing  of  the  atlas  penetrate  in  the 
direction  parallel  to  the  long  axis  of  their  fibers  the  aponeu- 
rotic expansion  of  the  mastoido-humeralis,  and  the  stylo- 
maxillaris  muscle.  The  puncture  is  thus  located  between 
the  ninth  and  tenth  nerves  on  one  side  and  the  internal 
carotid  artery  on  the  other.  Since  the  wall  of  the  guttural 
pouch  rests  against  the  median  side  of  the  digastricus 
or  sterno-maxillaris  muscle  it  is  opened  by  this  incision. 
The  operator  inserts  an  index  finger  along  the  blade  of  the 
knife  at  first  and  then  withdrawing  the  instrument  passes 
the  other  index  finger  also  into  the  penetrant  wound  and 
by  forcibly  parting  these,  dilates  it.  The  abnormal  contents 
are  then  removed  by  means  of  forceps,  curetting  and  irriga- 
tion. In  order  to  prevent  adhesion  of  the  wound  lips  in 
the  firmly  stretched  stylo-maxillaris  muscle,  introduce  a 
strong  drainage  tube  into  the  pouch  and  fix  it  to  the  external 
borders  of  the  wound  by  a  suture. 

III.  Dieterich' s  method.  This  operation  is  effected  at  a 
point  between  I  and  II,  the  opening  of  the  pouch  being 
made  immediately  behind  the  stylo-maxillaris  muscle.  In 
order  to  accomplish  this  the  cutaneous  wound  over  the  wing 
of  the  atlas  must  be  prolonged  below  it.  After  detaching 
the  posterior  border  of  the  parotid  gland  the  operator 
searches  in  the  loose  areolar  tissue  with  the  index  finger  of 
the  left  hand  for  the  vascular  angle  which  is  formed  by  the 
occipital,  internal  carotid  and  external  carotid  arteries  which 
may  be  detected  by  pulsation— the  same  is  located  at  a  depth 
of  from  8  to  10  cm.  Place  the  volar  surface  of  the  finger 
in  the  vascular  angle  and  push  a  sharp  scalpel  along  its 
dorsal  side  to  the  pouch  which  here  becomes  opened  on  its 
posterior  lateral  surface. 


76 


TA'ACHEOTOMY 


This  method  has  the  advantage  over  Chabert's  that  for 
the  removal  of  hard  contents  (chondroids)  the  opening  can 
be  readily  dilated,  even  to  such  an  extent  that  the  entire 
hand  may  be  passed  into  the  air  sac  and  the  opening  of  the 
Eustachian  tube  be  explored  as  in  Yiborg's  operation. 


12.     TRACHEOTOMY. 
Fig.  2. 


Instruments.  Razor,  scissors,  convex  scalpel,  tenacula, 
tenaculum  and  ligation  forceps,  trachea  tube,  and  suture 
material. 

Technic.  In  the  superior  third  of  the  cervical  region, 
in  the  neighborhood  of  the  fourth  to  the  sixth  tracheal  ring, 
shave  and  disinfect  the  skin  on  the  anterior  surface  of  the 
neck  to  the  extent  of  lo  cm.  long  by  5  cm.  wide.  The 
operation  is  best  performed  upon  the  standing  animal  with 
the  head  extended.  In  lateral  decubitis  the  operation  is 
carried  out  with  some  difficulty,  and  generally  the  operator 
fails  to  get  the  incision  on  the  median  line.  The  operator 
stands  before  the  right  shoulder  of  the  horse  with  an 
assistant  opposite  him. 

Render  the  skin  tense  along  the  median  line  of  the 
trachea  with  the  left  hand  and  then  make  a  drawing  cut  5 
to  8  cm.  long  from  above  to  below  with  the  scalpel.  The 
incision  should  be  made  carefully  upon  the  median  raphe  of 
the  skin  which  is  virtually  destitute  of  sensation  and  requires 
no  anaesthesia.  After  the  skin  muscle  is  cut  through,  in 
order  to  avoid  hemorrhage,  separate  the  two  sterno-thyro- 
hyoideus  muscles  by  means  of  tenacula  along  the  median 
raphe  in  the  white  strip  of  connective  tissue.  The  opening 
into  the  trachea  may  be  made  in  a  variety  of  ways.  The 
quickest  and  most  crude  method  is  to  slit  it  from  above 
downwards  through  two  or  three  tracheal  rings,  and  press- 


TRACHEOTOMY. 


77 


ing  the  several  ends  apart  insert  the  tube  through  the  open- 
ing. Since  the  tracheal  rings  are  incomplete,  being  open 
on  their  dorsal  surfaces,  cutting  through  the  ventral  portion 
divides  each  ring  into  two  separate  parts  and  their  being 
pushed  apart,  distorts  them  and  tends  to  the  causation  of 
chondritis  and  collapse  of  the  trachea,  a  danger  which  in- 
creases with  the  duration  of  time  that  the  tube  is  maintained 
in  position.  It  is  therefore  most  suitable  for  hurried  opera- 
tion in  impending  suffocation  where  the  tube  will  probably 
be  needed  for  a  short  time  only. 


Tracheotomy,  s,  sterno-thyro-hyoideus  muscle  ;  /,  trachea  ; 
sch,  mucous  membrane  of  the  posterior  wall  of  the  trachea  ; 
/,  interannular  ligament. 

A  second  method  of  operation,  illustrated  in  Fig.  2,  con- 
sists in  making  a  transverse  incision  through  the  inter-annu- 
lar ligament  between  the  two  last  exposed  tracheal  rings  the 
length  of  the  diameter  of  the  tube  to  be  inserted.  Make 
a  perpendicular  incision  upward  from  each  end  of  this  at  a 
point  I  to  1.5  cm.  from  the  median  line  through  one  or  two 
tracheal  rings,  according  to  the  size  of  the  tube.  With 
forceps  or  tenaculum  grasp  the  segments  of  partially  de- 


78 


THE  OPERA  riON  FOR  ROARING. 


tached  cartilage  and  remove  them  by  cutting  through  the 
inter-annular  ligament. 

A  third  and  to  us  preferable  method  is  to  insert  a  narrow 
bladed  scalpel  transversely  at  about  the  lower  third  of  the 
lowermost  bared  tracheal  ring  and  cutting  outwards  and 
upwards  in  a  curved  line,  pass  through  the  first  inter-annu- 
lar ligament  and  continue  into  the  succeeding  segment  until 
near  its  superior  border,  when  the  incision  is  curved  down- 
ward to  eventually  reach  the  starting  point,  the  isolated 
section  of  the  trachea  being  securely  grasped  with  a  pair  of 
forceps  before  its  excision  is  completed.  By  this  method 
no  tracheal  ring  is  severed. 

The  trachea  tube  is  to  be  removed  and  cleansed  daily  as 
long  as  its  use  is  necessary,  and  when  discontinued  the 
wound  should  be  left  open  and  dressed  antiseptically. 


13.     THE  OPERATION  FOR  ROARING. 
Plate  XV.     Figs.   3-5. 

Instruments.  Razor,  hypodermic  syringe,  scalpels, 
tenaculum,  artery  forceps,  laryngeal  speculum,  two  long 
curved  dressing  forceps,  hard  rubber  syringe  with  long  pipe, 
ventricular  burr,  reflecting  lamp,  razor-shaped  scalpel,  long 
curved  scissors. 

The  following  technic  has  for  its  aim  two  fundamental 
objects  which  are  to  be  kept  constantly  in  mind  : 

I.  It  is  aimed  to  bring  about  a  prompt,  firm,  complete 
and  permanent  adhesion  of  the  arytenoid  cartilage  and  vocal 
cord  against  the  inner  face  of  the  thyroid  cartilage  in  the 
normal  position  of  forced  iu.spiration,  so  that  no  air  can 
become  impacted  into  the  ventricle  to  force  the  vocal  cords 
and  arytenoid  cartilage  downwards  and  inwards  to  obstruct 
the  free  ingress  of  air. 


THE  OPERATION  FOR  ROARING.  79 

2.  It  is  aimed  to  complete  the  operation  without  wound- 
ing a  cartilage  either  in  the  essential  operation  when  re- 
moving the  ventricular  mucosa,  during  the  invading  incision 
through  the  crico-thyroidean  membrane,  and  later,  should 
dyspnoea  occur,  by  inserting  the  laryngeal  tube  through 
the  existing  incision  instead  of  performing  tracheotomy. 

Technic.  Docile  animals  are  readily  operated  upon  in 
the  standing  position.  The  animal  should  be  confined  in 
stocks,  or  otherwise,  in  such  a  manner  that  his^head  may 
be  securely  held  in  an  elevated  and  extended  position.  The 
safety  of  the  operator  further  demands  that  the  patient 
shall  be  so  secured  that  he  can  neither  rear  nor  strike. 

Resistant  animals  need  be  cast  or  confined  upon  the 
operating  table.  General  anaesthesia  upon  the  recumbent 
animal  is  usually  unnecessary,  and  is  only  demanded  in  those 
cases  of  unusual  resistance  to  confinement,  where  the  patient 
may  injure  itself  by  its  violent  struggles. 

Ordinarily  ample  anaesthesia,  whether  from  the  stand- 
point of  surgical  efficiency  or  of  sentiment,  is  obtainable  by 
the  use  of  local  anaesthetics,  preferably  of  cocaine  and 
adrenaline. 

Shave  and  disinfect  the  operative  area,  and  inject  sub- 
cutaneously  a  sufficient  amount  of  the  local  anaesthetic. 

Make  a  longitudinal  incision  over  the  larynx  through  the 
skin  and  fascia  as  accurately  as  possible  on  the  median 
raphe,  commencing  opposite  to  the  anterior  extremity  of 
the  thyroid  cartilage  and  extending  downward  and  back- 
ward to  the  region  of  the  first  tracheal  ring.  Separate  the 
sterno-thyro-hyoideus  muscle  on  the  median  line  with  the 
scalpel  blade  or  handle  as  preferred.  Control  the  hem- 
orrhage. If  the  operation  is  performed  upon  the  standing 
animal  with  the  aid  of  cocaine  and  adrenaline,  the  incision 
is  virtually  bloodless. 

Locate  the  crico-thyroidean  ligament,  triangular  in  form, 
bounded  anteriorly  and  on  both  sides  by  the  thyroid  cartilage 


Plate  XV. 
Operation  for  Relief  of  Roaring. 

Fig.  I.  Longitudinal  section  through  the 
ventricle  of  the  larynx  ;  A,  arytenoid  cartilage  ; 
TA,  anterior  fasiculus  of  thyro-arytenoideus 
muscle  ;  TA^,  posterior  bundle  thyroarytenoid- 
eus  ;  VC,  vocal  cords  ;  V,  laryngeal  ventricle  ; 
T,  thyroid  cartilage  ;  E,  epiglottis. 

Fig.  2.  Sagittal  section  of  the  larynx.  C, 
cricoid  cartilage.    Other  lettering  same  as  Fig.  i. 


TA     y      tX  .VC 


Fig.  2. 


THE  OPERA  TION  FOR  ROARING. 


83 


and  posteriorly  by  the  cricoid  ring.  Error  may  occur  here 
and  the  space  between  the  cricoid  and  first  tracheal  rings  be 
mistaken  for  the  crico-thyroidean  ligament.  This  is  readily 
obviated  by  careful  digital  palpation,  which  reveals  the 
triangular  crico-thyroidean  ligament  with  its  rounded  apex 
directed  forward  and  its  lateral  borders  sharply  defined  by 
the  hard  borders  of  the  alse  of  the  thyroid  cartilage,  while 
the  base  of  the  triangle  rests  upon  the  more  elastic  anterior 
border  of  the  cricoid  cartilage. 


Fig.  3. 

Laryngeal  dilator  in  position. 

Having  carefully  identified  the  crico-thyroidean  ligament, 
place  the  back  of  the  scalpel  against  the  anterior  border  of 
the  cricoid  cartilage,  accurately  upon  the  median  line,  the 
point  directed  obliquely  backwards  toward  the  cavity  of  the 
trachea.     Push  the  scalpel  through  the  ligament  into  the 


84 


THE  OPERATION  FOR  ROARING. 


laryngeal  cavity,  and  carry  the  incision  forwards  on  the 
median  line  to  the  body  of  the  thyroid  cartilage. 

Detach  the  slotted  piece  from  the  laryngeal  retractor  (Fig. 
4)  and  insert  the  closed  retractor  into  the  incision  through 
the  ligament,  the  ratchet  end  of  the  speculum  being  directed 
toward  the  trachea,  the  curved  spurs  on  the  jaws  of  the 
retractor  resting  within  the  cricoid  ring.  Open  the  dilator 
to  the  full  extent  of  the  crico-thyroidean  space.  Insert  the 
hook  of  the  slotted  piece  into  the  cavity  of  the  thyroid 
cartilage  and  secure  in  position  by  means  of  the  thumb  screw. 

Illuminate  the  cavity  of  the  larynx.  In  the  standing 
animal,  when  facing  good  light,  the  natural  illumination 
suffices.  The  illumination  may  be  improved  with  the  aid 
of  a  hand  mirror. 

Excellent  illumination  is  always  available  by  means  of  a 
reflecting  electric  lamp.  With  a  good  lamp  the  illumination 
may  be  perfectly  controlled  in  a  dark  room  or  in  the  dark- 
ness of  night.  When  the  animal  is  cast  and  turned  upon 
his  back,  the  light  rays  should  enter  the  larynx  from  above 
obliquely  downward  and  forward.  If  the  operation  is  being 
done  in  the  open  field  by  sunlight,  the  patient's  head  should 
be  directed  away  from  the  sun,  or  good  illumination  fails. 

Observe  the  motion  of  the  arytenoid  cartilages,  and 
determine,  if  not  previously  done,  whether  the  unilateral  or 
bilateral  operation  is  to  be  performed.  Inject  into  the 
larynx  and  laryngeal  ventricle  or  ventricles  a  sufficient 
quantity  of  a  solution  of  cocaine  and  adrenaline  to  blanch 
and  anaesthetize  the  mucosa.  The  ventricles  are  more  con- 
veniently injected  if  the  syringe  nozzle  is  bent  near  the  tip. 

The  ventricles  commonly  contain  some  mucus,  which 
interferes  with  the  securing  of  the  mucosa  and  should  be 
taken  up  and  removed  by  means  of  a  small  piece  of  absorbent 
cotton  pressed  into  the  ventricle  with  the  long  curved  dres.s- 
ing  forceps. 

When  the  ventricular  mucosa  has  been  effectively  anaes- 
thetized introduce  the  burr  into  the  ventricle  and  draw  the 


THE  OPERATION  FOR  ROARING. 


8  s 


sheath  on  the  burr  shaft  away  from  the  burr  for  the  distance 
of  about  I  cm.  Press  the  burr  gently  against  the  bottom  of 
the  ventricle,  hold  the  canula  to  prevent  its  revolving,  and 
give  the  burr  one  or  two  turns  to  the  right  until  the  re- 
sistance indicates  that  the  mucosa  is  securely  engaged. 
The  canula  is  now  pushed  against  the  burr  and  gentle 
traction  applied  to  the  handle,  revolving  the  burr  and  canula 


1 


Fig.  4.  Fig.  5. 

Laryngeal  dilator.  Ventricular  burr,  modified 

after  Blattenberg. 

now  and  then  a  trifle,  until  the  everted  mucosa  from  the 
bottom  of  the  ventricle  appears  beyond  the  mouth  of  the 
ventricle.  Grasp  the  everted  portion  of  the  muco.sa  securely 
with  the  long  curved  dressing  forceps  and  then  continue 
traction  with  these  until  the  ventricular  mucosas  has  been 
completely  everted.  Then  cut  away  the  everted  mucosa  by 
excising  it  with  the  razor-shaped  scalpel  or  by  means  of 


86  THE  OPERATION  FOR  ROARING. 

long  scissors  at  approximately  the  point  indicated  by  the 
dotted  line  in  Plate  XV. 

If  the  right  side  of  the  larynx  appears  to  be  affected  also, 
or  if  for  other  reasons  it  seems  desirable,  repeat  the  operation 
upon  the  right  ventricle. 

(The  operation  may  also  be  performed  without  the  use  of 
the  ventricular  burr,  but  it  is  more  difficult,  especially  upon 
the  standing  animal.  The  technic  is  the  same  until  the 
removal  of  the  ventricular  mucosa  is  reached,  when,  instead 
of  the  burr,  the  mucosa  of  the  ventricle  at  its  arytenoid 
border  is  grasped  with  the  forceps,  tension  is  applied,  and 
the  mucosa  is  incised  along  the  arytenoid  border  and  thence 
along  the  summit  of  the  vocal  cord.  The  incision  is  con- 
tinued at  the  point  indicated  by  the  dotted  line  in  Plate  XV 
until  the  ventricular  mucosa  has  been  isolated  from  that  of 
the  larynx  in  general.  Cautiously  exerting  tension  with 
the  forceps  upon  the  incised  border  of  the  ventricular 
mucosa,  dissect  it  away  from  the  loose  underlying  areolar 
connective  tissue  either  with  the  Moeller  razor-shaped 
scalpel  or  with  a  scalpel  handle.) 

However  the  mucosa  is  removed  the  operator  should  take 
care  that  the  removal  is  complete,  since  any  remnant 
incautiously  left  behind  in  the  ventricle  may  prevent  the 
desired  adhesion  of  the  arytenoid  to  the  thyroid  cartilage  or 
a  small  patch  of  mucosa  being  left  deep  in  the  ventricle 
might  permit  adhesion  of  other  parts,  imprisoning  the 
mucous  islet  and  ending  in  a  mucous  cyst. 

When  the  mucosa  has  been  removed  from  one  or  both 
ventricles,  all  blood  coagula  should  be  wiped  away,  any 
shreds  of  tissue  removed  and  the  denuded  tissues  painted 
over  with  tincture  of  iodine.  The  application  of  the  tincture 
of  iodine  is  best  made  with  the  long  curved  dressing  forceps 
carrying  a  small  pledget  of  cotton  saturated  with  the  drug. 
The  operator  needs  have  care  in  this  application  lest  the 
horse  in  forcible  expiration  blow  some  of  the  iodine  in  his 
face  and  eyes. 


THE  OPERATION  EOR  ROARING.  87 

If  the  patient  has  been  cast,  anaesthetized  and  turned 
upon  his  back,  turn  him  upon  his  side,  remove  the  confining 
apparatus,  and,  while  he  is  recovering  from  the  anaesthesia, 
keep  the  laryngeal  incision  open  and  the  larynx  free  from 
blood.  The  hemorrhage  from  the  operation  is  the  greatest 
when  it  has  been  performed  under  general  anaesthesia,  less 
if  cast  and  the  operation  performed  under  local  anaesthesia 
and  by  far  least  of  all  when  it  is  performed  upon  the  stand- 
ing animal  with  the  aid  of  cocaine-adrenaline  anaesthesia. 

As  soon  as  the  operation  has  been  completed  upon  the 
standing  animal,  the  head  may  be  released  and  the  patient 
returned  to  the  stall.  It  may  be  allowed  to  eat  or  drink  at 
convenience.  The  same  is  true  of  the  patient  cast  for  the 
operation,  and  only  local  anaesthesia  applied.  Patients 
cast  and  chloroformed  should  be  prevented  from  eating  or 
drinking  for  some  hours  and  should  be  fed  sparingly  for 
three  or  four  days. 

During  the  first  48  hours  after  operating,  especiall}^  after 
the  bilateral  operation,  the  patient  should  be  closely  watched 
in  reference  to  dyspnoea  either  from  hematoma  in  the 
ventricles  or  from  edema  or  emphysema  of  the  parts.  If 
dyspnoea  becomes  at  all  apparent,  tracheotomy  should  be 
promptly  performed,  or  what  we  greatly  prefer,  a  laryngeal 
tube  should  be  inserted  and  fixed  securely  to  the  margins 
of  the  external  wound  by  means  of  stout  sutures,  and  further 
security  given  by  passing  strong  tapes  about  the  neck  and. 
tying  firmly. 

Ordinarily  the  ventricular  wounds  should  not  be  disturbed, 
after  the  operation.  The  external  wound  should  be  dressed 
antiseptically  daily  till  healed  ;  a  period  of  about  three 
weeks.  Horses  used  for  ordinary  work  purposes  may 
usually  be  returned  to  their  work  after  five  to  six  weeks. 


S8  INTKA  I  'ENO US  IXJECTIOX. 

14.     INTRA-TRACHEAL  IRRIGATION. 

Objects.  The  washing  out  of  oils  or  other  insoluble  or 
irritant  substances  accidentally  introduced  into  the  trachea 
and  bronchi  while  drenching  or  otherwise,  and  the  disin- 
fection of  the  trachea  and  bronchi. 

Instruments.  Same  as  for  tracheotomy,  and  a  gravity 
irrigating  apparatus  fitted  with  3  m.  of  rubber  tubing  about 
I  cm.  in  diameter,  5  liters  of  .6  per  cent,  sodium  chloride 
solution  at  a  temperature  of  37  to  39°  C.  In  cases  of 
suppurative  bronchitis,  peroxide  of  hydrogen  may  be  added 
to  the  solution. 

Technic.  Operate  on  the  standing  animal.  Perform 
tracheotomy  (page  76).  Elevate  the  gravity  apparatus 
containing  the  irrigating  fluid  i  to  2  m.  above  the  patient, 
have  the  animal's  head  slightly  elevated,  insert  the  free  end 
of  the  rubber  hose  in  the  trachea  tube  and  let  the  fluid  flow 
into  the  trachea  in  a  moderate  stream  until  it  is  filled  and 
the  animal  makes  expulsive  efforts,  when  the  inflow  is 
stopped  and  the  animal  permitted  to  lower  his  head  and 
expel  the  fluid,  then  raise  the  head  again  and  repeat  until 
the  fluid  is  expelled  clear.  Repeat  the  operation  according 
to  requirement. 


15.     INTRAVENOUS  INJECTION. 

Fig.   6. 

Instruments.      Scissors,  hypodermic  syringe. 

Technic.  The  operation  is  performed  on  the  standing 
animal  on  either  jugular  vein  at  about  the  juncture  of  the 
upper  and  middle  thirds  of  the  neck  ;  to  most  operators  the 
right  jugular  is  the  more  convenient.  At  the  place  desig- 
nated the  subscapulo-hyoideus  muscle  lies  between  the 
jugular  vein  and  the  carotid  artery  and  affords  some  pro- 
tection against  injury  of  the  latter.     After  clipping  the  hair, 


INTRAVENOUS  INJECTION.  89 

the  skin  should  be  carefully  disinfected  preferably  with 
tincture  of  iodine.  The  vein  lies  in  the  jugular  groove 
between  the  mastoido-humeralis  and  the  sterno-maxillaris 
muscles  covered  only  by  the  skin  and  skin  muscle. 

Stand  by  the  shoulder  of  the  horse  and  compress  the 
jugular  with  the  thumb  as  shown  in  Figure  6  or  with  the 
second  to  the  fourth  fingers,  in  which  case  the  ball  of  the 
thumb  rests  on  the  mastoido-humeralis  muscle,  in  a  way  that 
the  vein  becomes  filled  above  the  point  of  compression  in  the 


Fig.  6. 

Intravenous  Injection. 

shorn  area  and  stands  out  as  a  swollen  cord.  In  the  case 
of  fleshy  necked  horses  efficient  compression  is  more  readily 
attained  if  the  head  is  somewhat  elevated  and  extended  by 
an  assistant.  If  the  vein  cannot  be  made  prominent  in  this 
way  the  compression  should  be  alternately  applied  for  a 
time  and  then  withdrawn  suddenly,  when  the  course  of  the 
vein  reveals  itself  by  a  wave-like  movement  along  the 
jugular  groove. 


go  INTRA  I  UNO  US  INJECTION. 

In  cattle  digital  compression  of  the  jugular  is  not  usually 
efficient  in  causing  distension.  It  is  more  practical  to  dis- 
tend the  jugular  by  passing  a  looped  cord  around  the  base 
of  the  neck  and  drawing  it  tightly.  The  very  conical  neck 
of  the  cow  tends  to  cause  the  cord  to  slip  forward  and  loosen, 
which  may  be  obviated  by  having  an  assistant  grasp  the 
cord  at  the  top  of  the  neck  and  hold  it  in  place.  A  very 
efficient  method  for  distending  the  jugular  of  the  cow  is  to 
stretch  a  strong  cord  tightly  between  two  posts  at  the 
heighth  of  the  base  of  the  neck,  lead  the  animal  against  it 
and  secure  the  head  firmly  to  a  post  in  front  of  the  animal 
sufficiently  tight  to  cause  the  lower  part  of  the  neck  to 
press  firmly  against  the  cord. 

Just  above  the  point  of  compression  the  vein  is  the  most 
fully  distended  and  firmly  fixed.  After  testing  the  hypo- 
dermic needle  to  see  that  it  is  open  hold  it  between  the 
second  and  third  fingers  while  the  thumb  covers  its  basal 
opening  and  thrust  it  through  the  skin,  cutaneous  muscle 
and  jugular  wall,  in  the  direction  of  the  vein  obliquely  for- 
wards and  upwards  i  to  2  cm.  deep,  so  that  the  point  of  the 
needle  enters  the  vessel  at  its  most  distended  part.  In  this 
way  it  is  easy  to  prevent  injury  to  the  median  wall  of  the 
vein.  If  the  vein  has  been  properly  punctured  blood  will 
flow  from  the  needle  upon  the  removal  of  the  thumb.  If 
the  vein  is  not  entered  at  the  first  attempt  the  needle  should 
be  partly  withdrawn  and  then  pushed  in  again  in  a  slightly 
different  direction. 

Be  careful  that  the  hypodermic  syringe  contains  no 
air.  The  material  to  be  injected  should  be  zvarmed  to  approxi- 
mately the  body  temperature.  The  syringe  is  then  connected 
with  the  needle  and  the  contents  slowly  discharged  into  the 
vein.  In  withdrawing  the  needle  be  careful  to  press  the 
skin  firmly  against  the  underlying  part.  The  omission  of 
this  precaution  frequently  results  in  the  formation  of  a 
subcutaneous  hematome. 


PHLEBOTOMY.  gi 

16.     PHLEBOTOMY. 
Fig.   6. 

Instruments.  Razor  or  scissors,  fleams,  lancet,  phle- 
botomy trocar,  spring  lancet,  pins,  suture  material. 

Technic.  a.  Phlebotomy  zvith  fleams  may  be  performed 
on  either  jugular  vein.  The  operation  is  preferably  carried 
out  on  the  standing  animal,  but  is  not  difficult  when  the 
patient  is  recumbent.  The  point  of  operation  is  at  about 
the  boundary  line  between  the  upper  and  middle  cervical 
regions,  because  it  is  here  that  the  subscapulo-hyoideus 
muscle  which  separates  the  jugular  vein  from  the  carotid 
artery  is  most  voluminous  and  consequently  affords  the 
greatest  protection  to  the  latter.  At  this  point  cHp  or  shave 
and  disinfect  the  skin.  Grasp  the  extended  blade  of  the 
fleam  at  the  hinge  with  the  thumb  and  index  finger  of  one 
hand,  while  the  third  and  fourth  fingers  compress  the 
jugular  vein  at  a  point  far  enough  below  that  the  fleam 
blade  rests  upon  the  shaved  part.  In  fleshy-necked  animals 
the  course  of  the  vein  may  be  clearly  made  out  by  causing 
its  repeated  distension  and  relaxation.  In  some  very  heavy 
necked  horses,  or  in  very  restless  animals,  efficient  distension 
of  the  jugular  is  best  obtained  by  cording  the  neck  as 
described  under  "  Intravenous  Injection." 

It  is  well  to  be  careful  that  the  point  of  the  fleam  blade  is 
not  allowed  to  prick  the  skin  prematurely  and  render  the 
animal  restless.  The  instrument  should  be  held  perpen- 
dicular to  the  surface  and  parallel  to  the  long  axis  of  the 
vein.  The  most  elevated  point  of  the  vessel  should  be 
struck  by  the  blade  in  such  a  way  that  the  skin,  subcutan- 
eous muscle  and  jugular  wall  are  penetrated  parallel  to  the 
long  axis  of  the  vessel. 

Drive  the  fleam  blade  into  the  vein  by  a  short,  sharp  blow 
with  a  small  stick  of  heavy  wood.  The  extension  on  the 
fleam  blade  prevents  its  being  driven  too  deeply.     The  size 


g2  PHLEBOTOMY. 

of  the  blade  to  be  used  depends  upon  the  thickness  of  the 
skin  and  other  tissues  covering  the  vein.  If  the  vein  is 
opened,  dark  red  blood  escapes  from  the  wound  in  a  large 
stream.  If  the  operation  does  not  succeed  at  the  first  effort, 
one  should  select  an  undamaged  portion  of  the  skin  for  a 
second  attempt  so  that  the  opening  into  the  vein  may  be 
direct  and  clean. 

When  the  vein  is  opened  lay  the  instrument  aside.  The 
compression  of  the  vessel  must  be  continued  in  order  to 
insure  the  flow  of  blood,  to  prevent  aspiration  of  air  and 
also  to  provide  that  the  lips  of  the  skin  wound  shall  not  be- 
come displaced  in  relation  to  that  of  the  vein  by  which  the 
escape  of  blood  would  be  impeded  or  stopped.  The  flow  of 
blood  may  be  favored  by  inducing  masticatory  movements 
by  the  animal.  The  amount  of  blood  withdrawn  varies 
between  3  and  8  liters,  according  to  the  size  of  the  animal  and 
the  object  to  be  attained. 

The  wound  may  be  closed  by  an  interrupted  or  a  pinned 
suture.  For  the  latter,  relieve  the  compression  on  the  vein 
and  grasp  the  lips  of  the  skin  wound  between  the  finger  and 
thumb  and  stick  the  pin  perpendicularly  through  the  middle 
of  them  a  few  mm.  from  their  borders.  Apply  a  noose  of 
silk  ligature,  previously  prepared,  over  the  pin  and  close  and 
tie  the  loop.  In  applying  the  pin  and  loop,  take  care  not 
to  elevate  the  skin  from  the  underlying  part,  which  tends 
to  the  production  of  a  hematome. 

b.  With  the  lancet  the  operation  is  preferably  performed 
on  the  right  side  of  the  neck.  Compress  the  vein  as  illus- 
trated in  Fig.  6,  and  hold  the  lancet  between  the  thumb 
and  index  finger  in  such  a  manner  that  it  can  only  penetrate 
as  far  as  into  the  vein,  and  then  push  it  in  quickly  just  in 
front  of  the  compressing  thumb  through  the  skin,  subcutem 
and  venous  wall  as  deep  as  the  fingers  holding  the  lancet 
will  permit. 

Hold  the  blade  perpendicular  to  the  long  axis  of  the  vein, 
and    avoid    directing  the  point  dorsalwards,  which  would 


LIGATION  OF  THE  CAROTID  ARTERY. 


93 


endanger  the  superior  wall  of  the  vessel  or  cause  the  lancet 
to  glide  over  the  wall  and  not  enter  the  vein.  When  the 
lancet  has  entered  the  vein,  extend  the  wound  somewhat 
toward  the  head  by  flexing  the  hand  dorsally.  In  cattle  it 
is  necessary  to  compress  the  vein  by  means  of  a  cord  tightly 
drawn  around  the  neck,  the  operator  taking  the  same  posi- 
tion as  in  the  horse  while  an  assistant  holds  the  animal  by 
the  horns  or  nose,  or  the  vein  may  be  still  more  effectively 
distended  by  causing  the  patient  to  press  against  a  tightly 
stretched  cord  with  the  base  of  the  neck  as  advised  for 
intravenous  injection  on  page  88.     Close  the  wound  as  in  a. 

Phlebotomy  with  the  spring  lancet  is  carried  out  in  a 
similar  manner,  the  jugular  being  compressed  in  the  same 
way,  and  the  lancet,  with  the  spring  set,  placed  over  the 
vein  in  such  a  way  that  the  opening  will  be  made  in  the 
same  direction  and  manner  as  with  the  fleams.  The  lancet 
blade  is  then  released  and  penetrates  the  vein.  The  com- 
pression below  is  continued  as  in  other  cases. 

c.  Phlebotomy  with  the  trocar  is  performed  in  the  same 
manner  as  has  been  described  for  intravenous  injection.  So 
long  as  the  flow  of  blood  continues  the  compression  of  the 
vein  must  not  be  intermitted.  The  phlebotomy  trocar 
should  be  about  5  mm.  in  diameter. 


17.    LIGATION  OF  THE  CAROTID  ARTERY. 
Plate  XVI. 

Objects.  The  control  of  hemorrhage  from  wounds  or 
the  prevention  of  hemorrhage  during  the  removal  of  tumors 
or  other  operations  in  the  parotid  region. 

Instruments.  Scissors,  scalpel,  tenacula,  aneurism 
needle,  mouse-toothed  forceps,  ligation  forceps,  suture 
material. 

Technic.  The  operation  is  possible  on  the  standing 
animal  with  the  aid  of  cocaine  or  other  local  anaesthetic  but 


Plate  XVI. 

Fig.  I. — a,  Ligation'of  the  common 
carotid  artery  ;  b,  O^sophagotomy. 

Fig.  2. — Ligation  of  the  common 
carotid  artery  ;  c,  common  carotid 
artery; 7,  jugular  vein  ;  v,  vagus  nerve; 
s,  sympathetic  nerve ;  r,  recurrent 
nerve  ;  p,  cervical  panniculous  carno- 
sus  muscle  ;  ;//,  sternomaxillaris  mus- 
cle ;  .sV,  levator  humeri  musclf. 

Fig.  3. — ajsophagotomy.  c,  com- 
mon carotid  artery  ;  j\  jugular  vein  ; 
o,  o\  oesophagus  ;  s,  sympathetic 
nerve  ;  f,  trachea  ;  st,  masto'ido-hum- 
eralis  (lavator  humeri)  muscle. 


Fig.   1. 


LIGATION  OF  THE  CAROTID  ARTERY. 


97 


it  is  preferable  to  confine  the  patient  in  laternal  recumbency 
and  anaesthetize. 

The  operation  is  made  at  the  same  point  as  for  phlebotomy 
and  the  same  cutaneous  wound,  a,  Plate  XVI,  may  be  used 
for  this  purpose.  The  incision  should  be  at  least  lo  cm. 
long  extending  through  the  skin,  fleshy  panniculus  and 
subscapulo-hyoideus  muscles  and  then  a  passage  forced  with 
the  fingers  to  the  trachea.  At  the  region  of  the  neck  indi- 
cated, the  carotid  passes  along  the  border  between  the 
lateral  and  dorsal  surfaces  of  the  trachea,  accompanied 
dorsally  by  the  vagus  and  sympathetic  nerves  and  ventrally 
by  the  recurrent.  (In  Fig.  2,  Plate  XVI,  the  vagus  and 
sympathetic  nerves,  v  and  s,  are  pushed  out  of  their  normal 
position  and  appear  ventrally  to  the  carotid.)  Pass  the 
index  finger  over  and  behind  the  carotid  until  the  trachea 
is  reached,  and  encircling  the  inner  and  lower  sides  of  the 
artery,  force  a  way  through  the  surrounding  areolar  tissue 
and  draw  the  vessel  out  through  the  wound.  As  a  rule 
the  carotid  is  still  loosely  surrounded  by  connective  tissue, 
which  comes  from  the  deep  fascia  of  the  neck  and  in  which 
also  the  three  above  mentioned  nerves  are  found.  These 
nerves  must  be  carefully  separated  from  the  carotid  and 
must  on  no  account  be  included  in  the  ligature.  Ligate 
the  carotid  twice  with  an  interval  of  about  2  cm.  between 
the  two  ligatures  and  divide  the  artery  midway  between 
them.  The  second  ligature  is  necessary  in  order  to  prevent 
hemorrhage  from  the  distal  end  through  collateral  anasto- 
moses and  it  is  essential  to  sever  the  artery  in  order  to  avoid 
its  rupture  by  the  stretching  of  the  undivided  carotid  dur- 
ing movements  of  the  neck  where  the  nutrition  has  been 
cut  off  at  the  point  of  ligation.  Provide  drainage  for  the 
wound  and  suture  the  muscle  and  skin. 


g8  OESOPHA  GO  TO  MY. 

18.     OESOPHAGOTOMY. 
Plate  XVI. 

Instruments.  Razor,  scissors,  convex  scalpel,  straight 
probe-pointed  bistoury,  tenacula,  artery  forceps,  absorbent 
cotton,  suture  material. 

Technic.  The  operation  can  be  carried  out  on  the 
standing  or  the  recumbent  animal.  At  its  origin  the 
oesophagus  lies  above  the  trachea  somewhat  to  the  left  of 
the  median  line  and  as  it  decends  it  gradually  deviates 
farther  until  in  the  lower  cervical  region  it  lies  down  Slong 
the  left  side  of  the  trachea. 

The  operation  is  performed  at  any  point  between  the 
pharynx  and  chest  where  the  lodgment  of  a  foreign  body 
or  other  condition  may  demand  it.  When  the  oesophagus 
is  empty  the  operation  is  best  performed  in  the  lower  third 
of  the  neck  at  d,  Fig.  i,  Plate  XVI. 

An  incision  lo  cm.  long  through  the  skin  and  skin  muscle 
is  made  on  the  left  side  between  the  anterior  border  of  the 
mastoido-humeralis  muscle  and  the  jugular  vein.  With  the 
two  index  fingers  divide  the  loose  connective  tissue  down  to 
the  oesophagus,  which  lies  between  the  left  scalenus  muscle, 
trachea  and  jugular  vein.  Along  the  supero-external 
border  of  the  trachea  runs  the  carotid  artery,  accompanied 
dorsally  by  the  vagus  and  sympathetic  and  ventrally  by  the 
recurrent  nerves.  The  oesophagus  feels  like  a  round  muscle 
within  which  one  can  distinguish  a  firmer  cord,  the  mucous 
membrane.  When  brought  into  view  the  organ  has  a  pale 
red  color,  and  it,  with  the  trachea  is  surrounded  by  the 
deep  fascia  of  the  neck.  Pass  one  finger  around  the 
oesophagus  from  behind,  draw  it  away  from  the  trachea, 
force  a  passage  through  the  deep  fascia  of  the  neck  and 
draw  it  out  through  the  external  wound.  After  making  an 
incision  through  the  oesophageal  muscle  and  mucous  mem- 
brane introduce  a  probe  pointed  bistoury  or  a  scissors  blade 


OESOPHA  GO  TOM  } ' 


99 


into  the  lumen  of  the  oesophagus  and  split  its  wall.  The 
mucous  membrane  is  white  and  lies  in  thick  longitudinal 
folds. 

When  there  is  a  foreign  body  in  the  oesophagus  the 
operation  is  performed  at  the  point  where  it  is  lodged,  in 
the  maimer  described  and  the  incision  should  be  made  only 
large  enough  to  permit  its  removal.  In  diverticuli  of  the 
oesophagus  an  ellipical  piece  of  the  mucous  membrane 
which  has  been  overstretched  is  cut  out.  The  oesophageal 
wound  is  closed  by  a  laminated  suture,  that  is,  tlie  mucous 
membrane  is  united  by  means  of  an  intestinal  suture  and 
the  muscular  wall  closed  over  this.  The  skin  and  muscular 
wound  may  either  be  left  open  or  closed  with  the  Bayer 
suture  and  bandaged,  with  a  drainage  tube  in  the  lower 
angle. 


III.     OPERATIONS  ON  THE  TRUNK  AND 
GENITAL  ORGANS. 

19.    PUNCTURE  OF  THE  CHEST. 

Fig.   7. 

Objects.     The  relief  of  hydrothorax  or  pyothorax. 

Instruments.  Razor,  scissors,  trocar,  i  m.  of  rubber 
tubing  of  the  same  size  as  the  trocar,  vessel  for  receiving 
the  escaping  fluid,  dressing  material. 

Technic.  Operate  upon  the  standing  animal,  the  point 
of  operation  in  the  horse  being  the  seventh  intercostal  space 
on  the  left  side,  and  the  sixth  on  the  right.     Dogs  may  be 


Fig.   7. 

Puncture  of  the  chest  ;  puncture  of  the  intestine. 

laid  upon  the  table.  The  anterior  ribs  are  so  covered  by 
the  shoulder  that  they  cannot  be  counted  from  before  back- 
wards and  must  be  enumerated  from  behind  forwards.  In 
the  horse  there  are  usually  eighteen  ribs  and  in  the  dog 
fourteen.     Counting  ii  or  12  intercostal  spaces  from  behind 


PUNCTURE  OF  THE  INTESTINES.  loi 

we  reach  in  the  horse  the  point  of  operation  on  the  left  and 
right  sides  respectively.  Clip  or  shave  the  designated  inter- 
costal area  immediately  above  the  thoracic  vein.  Grasp  the 
trocar  firmly  with  the  thumb  and  index  finger  of  one  hand 
at  such  a  distance  from  the  point  as  will  permit  the  canula 
to  enter  the  chest.  After  the  skin  over  the  seat  of  operation 
has  been  drawn  aside  by  the  hand,  place  the  trocar  at  the 
anterior  border  of  the  rib  with  the  point  inclined  slightly 
forward  and  with  a  sharp  blow  with  the  palm  of  the  other 
hand  drive  the  instrument  through  the  skin,  cutaneous  and 
intercostal  muscles,  internal  thoracic  fascia  and  pleura  into 
the  pleural  sac.  When  the  resistance  ceases,  the  thoracic 
cavity  has  been  entered.  Remove  the  stilette  and  permit 
the  pus,  lymph,  or  other  fluid  to  escape.  This  flow  is  at  first 
continuous,  but  later  becomes  rythmic,  synchronous  with 
respiration.  The  intermission  of  the  flow  during  inspiration 
permits  air  to  enter  the  pleural  cavity  unless  precautions 
are  taken  against  it ;  this  is  most  readily  obviated  by  slipping 
one  end  of  the  rubber  tubing  over  the  exposed  part  of  the 
canula  and  placing  the  other  extremity  in  the  receptacle  for 
the  fluid  where  it  will  be  submerged.  This  will  not  only 
prevent  aspiration  of  air  into  the  chest  but  will  act  as  a 
siphon  to  aid  in  the  withdrawal  of  the  fluid  from  the  pleu- 
ral cavity.  In  the  absence  of  the  tubing  the  entrance  of 
air  may  be  avoided  by  closing  the  canula  with  the  finger 
after  each  expiration. 


20.     PUNCTURE  OF  THE  INTESTINES. 

Figs.   7-8. 

Object.      The  relief  of  intestinal  tympany. 

Instruments.     Razor,  scissors,  trocar. 

Technic.  Puncture  of  the  intestine  is  preferably  per- 
formed on  the  standing  horse  but  may  be  carried  out  on  the 
recumbent  animal.     The  point  of  operation  is  in  the  right 


I02  PUNCTURE  OF  THE  INTESTINES. 

flank  about  equi-distant  from  the  last  rib,  the  extremities 
of  the  transverse  processes  of  the  lumbar  vertebrae  and  the 
external  angle  of  the  ilium  in  the  standing  horse  ;  at  the 
uppermost  point  of  the  abdomen  in  the  recumbent  animal, 
that  is,  at  the  most  prominent  part  of  the  distension.  After 
the  skin  at  this  place  has  been  clipped  or  shaved  and  disin- 
fected gasp  the  trocar  with  the  index  finger  and  the  thumb 
of  the  left  hand  and  holding  the  instrument  perpendicular 
to  the  body  surface,  give  it  a  firm,  quick  blow  with  the 
palm  of  the  right  hand  and  drive  it  through  the  abdominal 
wall  into  the  intestine. 

With  a  properly  constructed  trocar  of  the  dimensions 
suggested  in  Figure  8  no  preliminary  puncture  with  the 
lancet  is  required  or  advisable.  The  cutting  end  of  the 
stilette  should  be  very  long,  tapering  and  sharp  so  that  it 
will  cut  as  freely  as  a  lancet.  By  performing  the  opera- 
tion as  directed  the  trocar  ordinarily  punctures  the  caecum. 


Fig.  8. 

Intestine  trocar  with  sheath.     Outside  diameter  of  canida  3  mm., 
length  of  canula,  16  cm. 

Withdraw  the  stilette  and  permit  the  gas  to  escape 
through  the  canula.  The  canula  may  become  occluded  by 
particles  of  ingesta  entering  it  and  these  should  be  removed 
by  reinserting  the  stilette.  The  intestine  first  punctured 
may  collapse  and  the  flow  of  gas  cease  while  the  tympany 
continues  in  other  parts  ;  this  may  be  overcome  by  reintro- 
ducing the  stilette  and  pushing  the  trocar  through  the 
distal  wall  of  the  bowel  and  into  the  intestine  beyond.  If 
this  does  not  succeed,  the  trocar  may  be  withdrawn  and 
reinserted  in  a  neighboring  area  or  if  need  be  on  the 
opposite  side  of  the  animal. 


SUBCUTANEOUS  CAUDAL  MYOTOMY. 


103 


In  withdrawing  the  canula  replace  the  stilette  and  press 
the  skin  against  the  abdomen  with  the  thumb  and  finger  of 
one  hand  while  the  trocar  is  drawn  out  with  the  other. 
This  tends  to  prevent  particles  of  ingesta  from  following 
the  canula  out  of  the  intestine  and  becoming  lodged  at 
some  point  in  the  track  of  the  wound  to  set  up  inflammatory 
processes  there. 

Before  introduction,  the  trocar  should  always  be  rendered 
sterile  but  should  not  bear  irritant  antiseptics,  which  be- 
coming lodged  in  the  wound  tend  to  irritate  the  tissues  and 
produce  abscesses.  Puncture  of  the  intestine  is  so  often 
extremely  urgent  that  deliberate  aseptic  precautions  are  not 
always  practicable  and  trocarization  only  too  frequently 
results  in  abscesses  in  the  abdominal  wall.  Its  prevention 
must  depend  chiefly  upon  the  disinfection  of  the  skin  and 
instrument.  It  becomes  important  to  use  an  instrument 
which  is  clean  in  advance.  If  the  one  one  shown  in  Fig.  8 
is  well  disinfected  after  using  and  the  sheath  is  filled  with 
alcohol  before  it  is  screwed  on,  the  instrument  will  remain 
sterile  until  it  is  again  unsheathed  when  the  alcohol  will 
quickly  evaporate  and  leave  the  trocar  aseptic. 


21.    SUBCUTANEOUS  CAUDAL  MYOTOMY. 
Fig.   9. 

Object.     The  correction  of  curved  tail. 

Instruments.     Sharp  straight  tenotome,  bandage. 

Technic.  The  point  or  points  of  curvature  and  their 
extent  are  to  be  carefully  noted  by  having  the  animal  trotted 
away  from  the  operator.  The  curvature  is  generally  due  to 
unequal  development  of  the  two  levator  or  extensor  muscles, 
Fig.  9.-<?,  though  quite  rarely  the  depressors,/,  may  be 
implicated. 


J04  SUBCCTAXEOrS  CAUDAL  MVOTOMV. 

Confine  the  animal  in  stocks,  or  in  default  of  these,  con- 
■:trol  by  means  of  a  twitch  and  sideline.  Cleanse  and  disin- 
fect the  tail  and  have  it  sharply  bent  by  an  assistant  in  the 
opposite  direction  to  the  curvature.  Locate  the  longitudi- 
nal furrow  between  the  levator  and  depressor  muscles  on 
what  has  now  become  the  convex  side  and  at  the  lower 
margin  of  the  levator  and  just  above  v.  Fig.  9,  insert  the 
tenotome  at  the  most  prominent  part  of  curvation,  the 
incision  being  parallel  with  the  muscular  fibers,  and  push 


Fig.  9. 

Transverse  section  of  the  tail.  «,  caudal  vertebra  ;  c,  sacro- 
coccygeus  lateralis  muscle  ;  e,  sacro  coccygeus  superior  ;  f, 
depressor  longus  and  brevis  muscles  ( saero-coccygeus  infer- 
ior); 7,  intertransversales  muscles  ;  a,  coccygeal  artery  ;  5,  su- 
pero-lateral  coccygeal  artery  ;  /,  infero-lateral  coccygeal  ar- 
tery ;  -v,  caudal  veins  (dorsal,  ventral,  lateral)  ;  sch,  caudal 
fascia  ;  h,  skin. 

the  instrument  entirely  through  the  muscle  to  the  vertebra, 
then  turning  the  cutting  edge  upwards,  at  the  same  time 
advancing  the  point  toward  the  median  line,  .sever  the 
entire  muscle. 

The  superior  lateral  catidal  artery,  s,  Fig.  9,  bleeds  pro- 
fusely if  severed,  and  wounding  of  it  may  usually  be 
avoided  by  withdrawing  the  tenotome  a  trifle  in  passing 
that  point. 


CAUDAL  MYECTOMY. 


105 


Wounding  the  skin  over  the  muscular  incision  is  avoided 
by  placing  the  thumb  of  the  left  hand  over  the  line  of  in- 
cision so  the  knife  will  be  recognized  as  soon  as  the  muscle 
and  caudal  fascia  are  cut  through.  Remove  the  knife  in  the 
same  manner  as  introduced.  Release  the  horse  and  have 
him  trotted  again.  If  the  operatio7i  is  stifficient,  the  tail 
should  acrve  in  about  the  same  degree  as  before,  but  in  the 
opposite  direction.  If  this  has  not  been  attained  examine 
carefully  and  sever  any  remaining  bundles  of  muscle,  and 
this  not  sufficing  repeat  the  operation  as  before  at  another 
point  5  or  6  cm.  above  or  below  the  first,  severing  the  muscle 
again.  Or  if  the  depressor  appears  imphcated,  sever  it  in 
a  similar  manner.  In  extreme  cases  the  entire  lateral  half 
of  the  caudal  muscles,  tendons  and  aponeurosis  may  be 
severed. 

Apply  an  antiseptic  pad  to  the  wound  and  retain  it  by  a 
moderately  firm  bandage,  which  serves  at  once  as  an  occlu- 
sive dressing  and  effective  hemostatic.  Remove  the  band- 
age after  24  hours.  By  this  plan  of  operation  it  is  not 
intended  to  tie  the  tail  to  the  side  of  the  animal  during  the 
time  of  healing  but  when  bandaging  immediately  after  the 
operation,  the  tail  should  be  held  away  from  the  side  toward 
which  it  formerly  curved  so  that  the  bandage  may  tend  to 
prevent  the  return  of  the  organ  to  its  former  position. 


22.     CAUDAL  MYECTOMY. 
Fig.   9  and  Plate  XVII. 

Objects.  For  the  prevention  of  the  gripping  of  the  reins 
by  the  tail. 

Instruments.  Elastic  ligature,  straight  bistoury,  ten- 
acula,  absorbent  cotton,  bandages. 

Technic.  Confine  the  animal  in  lateral  decubitis  or  in 
stocks,  cleanse  and  disinfect  the  parts  and  apply  the  elastic 


Plate  XVII. 

Caudal  Myectomy   To  Prevent   Gripping 
of  the  Reins. 

DC,   Depressor  coccygeus  loiigus  muscle  ;  T, 
tourniquet. 


AMPUTATION  OF  TAIL.  109 

ligature  as  close  as  possible  to  the  root  of  the  tail.  Have 
an  assistant  hold  the  tail  upwards,  i.  e.,  dorsalwards,  and 
tightly  stretched.  Make  an  incision  15  to  20  cm.  long,  over 
the  middle  of  the  inferior  surface  of  each  depressor  longus 
muscle,  beginning  close  against  the  elastic  ligature  and  ex- 
tending toward  the  apex,  severing  at  once  the  skin  and 
caudal  fascia  down  to  the  muscle.  Let  an  assistant  retract 
the  lips  of  the  incision  with  tenacula  while  the  operator 
dissects  the  depressor  longus  muscle,  DC,  Plate  XVII,  from 
the  adjacent  tissues  at  either  side,  sever  it  by  a  transverse 
incision  close  against  the  ligature  and  dissect  away  the  en- 
tire muscle  down  to  the  lower  end  of  the  wound  and  there 
excise  it.     Repeat  the  operation  on  the  opposite  side. 

Make  two  elongated  tampons  of  absorbent  cotton,  of  the 
size  and  form  of  the  muscles  removed,  saturate  these  with 
i-iooo  sublimate  solution,  insert  neatly  in  the  wounds  and 
over  this  to  aid  in  securing  antisepsis  and  to  equalize  the 
pressure  apply  a  pad  of  absorbent  cotton,  saturated  with 
sublimate  solution,  covering  the  wounds  and  encircling  the 
tail  and  secure  by  a  moderately  firm  bandage  as  closely  as 
possible  to  the  elastic  ligature.  Remove  the  ligature,  when 
hemorrhage  may  ensue,  which  is  to  be  controlled  by  the  ap- 
plication of  a  second  bandage  extending  higher  up  on  the 
tail.  Remove  the  bandage  in  24  hours  and  dress  as  before 
for  a  second  day  after  which  treat  as  an  open  wound.  Care 
should  be  taken  to  not  apply  the  bandage  too  tightly  or 
leave  it  in  place  for  more  than  24  hours,  since  otherwise 
necrosis  of  the  tail  is  liable  to  occur  and  necessitate 
amputation. 


23.     AMPUTATION  OF  THE  TAIL. 
Plate  XVIII. 

Objects.  The  treatment  of  malignant,  or  incurable  dis- 
eases of  the  tail. 

Instruments.  Elastic  bandage,  scalpel,  razor,  artery 
forceps,  bone  cutting  forceps,  suture  material. 


Plate  XVIII. 
Amputation  of  the   Tail. 

Fig.  I. — Tail  amputated  showing  flaps  un- 
sutured ;  B,  Bandage  securing  hairs  turned 
upward  out  of  operator's  way. 

Fig.  2. — ^Operation  completed  showmg  su- 
tures ;  B,  Bandage  applied  to  secure  hairs  of  tail 
upwards  out  of  operator's  way. 


Fig.  1. 


Fig.  2. 


AMPUTATION  OF  THE  TAIL. 


113 


Technic.  The  animal  may  generally  be  operated  upon 
in  a  standing  position  secured  in  the  stocks  or  with  the  aid 
of  the  side  line.  lyocal  anaesthesia  may  be  applied  by  in- 
jecting cocaine  or  other  drug  deeply  upon  the  nerve  trunks 
as  well  as  just  beneath  the  skin.  The  animals'  attention 
may  be  attracted  by  means  of  the  twitch  if  found  necessary. 
The  point  of  amputation  is  determined  by  the  location  of 
the  disease.  Over  the  area  of  operation  clip  the  hair,  shave 
and  thoroughly  disinfect.  Apply  the  tourniquet  or  elastic 
bandage  at  the  base  of  the  tail  so  as  to  render  the  operation 
bloodless. 

Above  the  seat  of  operation  turn  the  hair  upward  toward 
the  root  of  the  tail  and  secure  it  there  by  means  of  the 
bandage,  B,  Fig.  i,  Plate  XVIII.  Locate  as  accurately  as 
possible  the  position  of  a  joint  at  the  point  where  it  is  desired 
to  operate  and  with  the  scalpel  begin  an  incision  on  the 
median  line  on  the  upper  side  of  the  organ  about  i  cm. 
above  the  articulation  and  carry  this  obliquely  outward  for 
a  distance  of  4  to  6  cm.  according  to  the  size  of  the  tail  and 
then  continue  it  downward,  backward  and  inward  along  the 
side  and  inferior  surface  until  directly  opposite  to  the  place 
of  beginning.  Make  a  similar  incision  upon  the  opposite 
side  of  the  tail,  cut  through  all  the  connective  tissue  and 
muscles  down  to  the  bone  and  then  disarticulate  with  the 
aid  of  the  scalpel.  Search  for  the  arteries  and  control  the 
hemorrhage  by  torsion  or  ligation.  The  vessels  will  be 
more  readily  found  by  loosening  the  tourniquet  so  as  to 
permit  the  blood  to  flow. 

Some  operators  prefer  to  begin  the  incision  at  the  side  of 
the  tail  instead  of  upon  the  dorsal  surface  and  in  that  way 
have  a  dorsal  and  ventral  flap  instead  of  right  and  left  as 
indicated  in  Fig.  i,  Plate  XVIII.  The  excision  having  been 
completed  the  flaps  are  brought  together  by  means  of  strong 
silk  or  silk  worm   gut   sutures  as  shown   in   Fig.  2.     The 


114 


URETHROTOMY.    LITHOTOMY. 


sutures  should  be  begun  at  the  apex  of   the  two  flaps  and 
comparative!}'  deep. 

Disinfect  the  stump  thoroughly  and  if  the  hair  is  suffici- 
ently long  it  is  well  to  draw  it  down  over  the  wound, 
to  which  an  antiseptic  covering  has  been  applied,  and  retain 
the  dressing  in  position  by  tying  a  cord  around  the  hair  just 
beyond  the  point  of  amputation. 


24.    URETHROTOMY.     LITHOTOMY. 
Figs.   10-11. 

Objects.  For  the  removal  of  calculi  from  the  bladder 
or  urethra  or  performing  other  operations  on  these  parts. 

Instruments.  Catheter,  convex  scalpel,  scissors,  artery 
and  compression  forceps,  tenacula,  lithotome,  lithotomy 
forceps,  lithotrite,  absorbent  cotton,  drainage  tube,  suture 
material. 

Technic.  Urethrotomy  may  be  performed  on  horses  in  a 
standing  position,  the  hind  feet  being  secured  with  hobbles. 

It  is  best,  however,  to  operate  under  anaesthesia  with  the 
patient  in  lateral  or  dorsal  recumbency,  either  on  the  operat- 
ing table  or  cast,  being  careful  to  .secure  as  gently  as  possi- 
ble, having  first  emptied  the  bladder  if  practicable,  since 
rupture  of  an  overdistended  viscus  may  readily  occur  during 
violent  struggles  by  the  animal. 

The  point  of  operation  will  depend  upon  the  location  of 
the  calculus  or  other  obstacle.  If  it  is  found  in  the  pelvic 
portion  of  the  urethra  or  in  the  bladder,  the  operation  is 
made  at  the  ischial  notch.  Fig.  lo.  First  the  penis  is  drawn 
out  from  the  prepuce  and  the  catheter  introduced  into  the 
urethra  and  pushed  upward  until  it  has  passed  the  ischial 
notch.  After  disinfection  of  the  skin,  render  it  tense  and 
make  a  ,5  cm.  long  incision  on  the  median  line  at  the  ischial 
arch  through  the  skin,  bulbo-cavernosus  muscle,  spongy 
portion  of  the  urethra,  and  the  urethral  mucous  membrane 


URETHROTOMY.     LITHOTOMY.  ^^ 

down  to  the  catheter,  Fig.  1 1 ,  k.  In  order  to  prevent  infil- 
tration of  urine  after  the  operation,  special  care  is  to  be 
taken  to  make  the  lower  end  of  the  wound  slanting  in  such 
a  manner  that  the  deeper  margin  is  higher  than  the 
superficial. 

After  the  catheter  has  been  drawn  back  away  from  the 
ischial  arch,  introduce  the  lithotomy  forceps  into  the  urethra 
or  bladder,  grasp  the  stone  and  draw  it  outward  in  its  natural 
direction.     The  grasping  of  the  stone  with  the  forceps  is 


Fig.  10. 

Urethrotomy  at  the  ischial  notch. 

materially  aided  by  means  of  the  left  hand  introduced  into 
the  rectum.  One  must  avoid  grasping,  along  with  the 
stone,  the  mucous  membrane  of  the  bladder.  Partial  filling 
of  the  bladder  with  a  tepid  aseptic  solution  will  aid  in  grasp- 
ing the  calculus  and  in  avoiding  the  implication  of  the 
bladder  walls.  Bj^  careful  rotary  movement  and  pushing 
the  forceps  backward  and  forward  the  operator  can  deter- 
mine before  traction  is  exerted  if  the  forceps  can  be  with- 


Ii6 


URETHROTOMY.      LITHOTOMY. 


drawn  easily  and  without  much  resistance  through  the  neck 
of  the  bladder. 

If  the  stone  is  so  large  that  it  cannot  pass  the  neck  of  the 
bladder  lithotripsy  may  be  performed.  This  operation  re- 
quires time  and  patience,  since  as  a  rule  it  is  not  possible  to 
encompass  the  entire  calculus  with  the  forceps.  That  is, 
the  narrowness  of  the  neck  of  the  bladder  prevents  the 
sufficiently  wide  opening  of  the  forceps.     The  stone  con- 


Fig.  11. 

Urethrotomy  (life  size),  /r,  skin;  a,  retractor  penis  muscle; 
/),  bulbo- cavernous  muscle  ;  r,  spongy  urethra  ;  //,  urethra  ; 
k,  catheter. 

sequently  must  be  gradually  broken  off  at  its  periphery  and 
the  individual  pieces  of  calculus  removed.  The  character 
of  the  surface  of  the  stone  has  an  evident  bearing  upon  the 
practicability  of  lithotripsy. 

The  surgical  dilation  of  the  pelvic  urethra  with  the 
lithotome  is  usually  far  more  practical  than  the  crushing  of 
the  stone.  Introduce  the  instrument  and  divide  the  urethra 
upward  on  the  median  line  as  the  instrument  is  withdrawn. 


AM  PUT  A  7  ION  OF  THE  PENIS.  1 1 7 

In  order  to  prevent  injury  to  the  rectum  it  should  be  emptied 
of  feces  before  the  operation  is  undertaken.  After  the  re- 
moval of  the  stone,  the  operator  may  push  the  catheter 
again  over  the  ischial  arch  and  unite  the  lips  of  the  wound 
in  the  urethral  mucous  membrane  by  means  of  intestinal 
sutures.  Flush  the  bladder  and  urethra  by  means  of  a 
warm,  3  per  cent,  boric  acid  solution  injected  through  the 
catheter  and  then  withdraw  the  latter.  Finally,  suture 
the  skin  wound  and  insert  a  drainage  tube  or  iodoform  gauze 
in  the  lower  angle. 

Or  the  whole  wound  may  be  left  entirely  open  and  dressed 
daily  with  antiseptics.  In  case  the  pelvic  urethra  has  been 
divided  the  suturing  of  the  external  wound  is  of  questionable 
utility. 

(For  student  practice  on  an  anaesthetized  horse,  intro- 
duce a  stone  into  the  bladder  through  the  urethral  wound 
and  practice  grasping  and  removing  it  with  the  lithotomy 
forceps. ) 


25.     AMPUTATION  OF  THE  PENIS. 
Plate  XIX  and  Fig.   12. 

Instruments.  Scalpel,  elastic  ligature,  strong  silk 
suture,  strong  piece  of  tape  i  m.  long,  artery  and  compres- 
sion forceps. 

Technic.  The  operation  is  carried  out  on  the  recumbent 
animal  under  local  or  general  anaesthesia,  the  upper  hind 
foot  being  drawn  backward  or  upward  or  otherwise  so  fixed 
as  to  not  obstruct  the  field  of  operation.  The  point  of 
operation  is  determined  by  the  character  of  the  disease  and 
the  object  to  be  attained.  It  may  be  made  at  any  point 
from  the  glans  penis  to  the  attachment  of  the  corpus  caver- 
nosum  to  the  ischium.  If  possible  amputate  in  front  of  the 
preputial  ring. 


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D 

t  AMPUTATION  OF  THE  PENIS.  121 

After  the  penis  has  been  drawn  out,  and  the  preputial 
region  carefully  cleansed  and  disinfected,  an  assistant  grasps 
the  organ  just  behind  the  preputial  ring  and  holds  it  firmly. 
A  catheter  is  then  introduced  into  the  urethra  and  pushed 
upwards  beyond  the  point  where  it  is  designed  to  amputate 
the  organ  and  a  temporary  elastic  ligature,  T,  is  then  applied 


Amputation  of  the  penis,  showing  needle  inserted  for  a  snture. 
V,  Dorsal  vessels  of  penis  ;  A,  Fibrous  tunic  of  the  corpus 
cavernosum  ;  S,  Skin  ;  CC,  Corpus  cavernosum  ;  CS,  Corpus 
spongiosum  of  urethra  ;  U,  Urethra. 

above  the  assistant's  liaiid  around  the  penis,  or  a  piece  of 
tape  is  looped  around  it  above  the  hand  and  is  made  to  serve 
both  as  a  tourniquet  and  as  a  means  for  holding  the  penis. 
Or  the  penis  may  be  grasped  in  front  of  the  ligature  with 
double  tenaculum  forceps  and  held. 


122  AMPUTATIOX  OF  THE  PENIS. 

Apply  a  small  cord  just  behind  the  glans  penis,  L,  Fig. 
I,  P  ate  XIX,  and  then  make  a  triangular  incision  on  the 
ventral  surface  of  the  organ  about  4  cm.  long  by  3  cm. 
wide,  the  base  of  the  triangle  being  forward  as  shown  in 
Fig.  I  ;  carry  this  incision  through  the  skin,  S,  the  corpus 
spongiosum,  CS,  and  along  the  corpus  cavernosum,  CC, 
down  to  the  urethra,  U.  Dissect  away  the  tissues  in  the 
triangular  area  without  opening  or  wounding  the  urethra 
and  when  this  has  been  completed  make  a  longitudinal 
incision  from  near  the  apex  of  the  triangle  to  its  base 
through  the  urethral  walls  to  the  catheter.  Beginning  at 
the  apex  of  the  triangular  wound  insert  a  series  of  inter- 
rupted sutures  as  shown  in  Fig.  2,  Plate  XIX  in  such  a 
manner  that  they  pass  through  the  urethral  wall  and  the 
skin  so  that  when  tied  the  wounded  surfaces  are  completely 
hidden  and  the  urethral  raucous  membrane  is  brought  into 
apposition  with  the  integument.  Continue  these  sutures 
down  to  the  base  of  the  triangle  after  which  remove  the 
catheter  and  excise  the  organ  by  a  cut  extending  in  a  slightly 
oblique  direction  from  below  upwards  and  forwards.  Take 
a  straight  needle  armed  with  the  silk  suture  and  passing 
it  through  the  margin  of  the  urethral  wound,  the  adjacent 
fibrous  capsule  of  the  corpus  cavernosum  and  across  but 
not  through  the  erectile  tissue,  insert  it  again  into  the 
superior  portion  of  the  fibrous  capsule  and  carry  it  out 
through  the  adjacent  dorsal  vessels  and  the  skin  as  shown 
in  Fig.  12,  and,  bringing  the  ends  of  the  sutures  together, 
tie  in  such  a  way  that  the  urethral  mucous  membrane  and 
the  margin  of  the  skin  are  brought  into  immediate  contact 
and  the  blood  vessels  securely  closed  in  such  a  manner  as  to 
guard  against  hemorrhage.  By  this  plan  when  the  sutures 
are  tied,  the  cut  borders  of  the  fibrous  envelope  are  brought 
together  over  the  erectile  tissue,  thus  preventing  hemor- 
rhage from  that  tissue  also.  Insert  as  many  sutures  as 
may  be  required  to  completely  and  securely  close  the  wound 


VA  GINAL  OVA  RIO  TOM  Y  IN  THE  MARE.         1 2  3 

and  finally  leave  every  part  wholly  covered  with  epithelium. 
By  this  plan  it  is  hoped  to  avoid  stricture  of  the  urethra  in 
the  process  of  healing.  Remove  the  tourniquet  and  release 
the  patient. 


26.    VAGINAL  OVARIOTOMY  IN  THE  MARE. 
Figs.   13-14. 

Objects.  The  alleviation  of  vice  when  related  to  ovarian 
irritation  or  disease. 

Instruments.  Colin's  scalpel,  ratchet  ecrasure,  55  cm. 
long,  vaginal  tensor. 

Preparation  of  patient.  It  is  highly  important  that 
the  animal  should  be  kept  on  a  scant  laxative  diet  for  at 
least  24  hours  and  preferably  longer  prior  to  the  operation, 
so  that  the  alimentary  canal  shall  be  somewhat  empty  and 
thus  decrease  the  intra-abdominal  tension  and  relieve 
the  operator  from  much  annoyance  due  to  the  pressure  of 
the  viscera. 

Technic.  The  vagina  of  the  mare  is  unique  in  its 
physiological  behavior.  Under  venereal  excitement  or  the 
introduction  of  the  operator's  hand  or  of  tepid  water  the 
organ  has  the  power  of  ' '  ballooning  ' '  or  dilating  to  a  degree 
not  so  marked  in  other  animals  ;  the  vaginal  walls  become 
erected,  hard,  and  stand  apart  from  each  other,  filling  the 
pelvic  cavity,  resting  firmly  against  the  pelvic  bones 
and  ligaments  at  every  part  except  at  the  points  where 
the  bladder  and  rectum  intervene  and  these  organs  are 
pressed  out  fiat  and  occupy  a  minimum  amount  of  space. 
In  the  quiescent  state  the  vaginal  walls  are  in  contact  and 
from  the  perinaeum  forward  to  within  about  10  cm.  of  the 
uterine  os,  the  vulva  and  vagina  are  connected  above  with 
the  rectum  by  the  pelvic  connective  tissue,  while  anterior 
to  this  point  the  vagina  is  covered  by  peritoneum,  and  it  is 


124 


VAGINAL  OVARIOTOMY  IN  THE  MARE. 


in  this  area  that  the  incision  needs  be  made  in  the  operation. 
The  ballooning  of  the  vagina  profoundly  alters  the  relation 
of  this  operative  area,  and  changes  it  from  the  horizontal 
in  the  quiescent  organ  to  the  perpendicular  in  the  ballooned 
condition.  These  variations  permit  of  two  methods  of 
operating  :  I.  On  the  ballooned  organ  without  anaesthesia 
and  with  the  animal  confined  in  the  standing  position.  II. 
On  the  quiescent  organ  in  the  recumbent  position  under 
anaesthesia  : 

I.    Without  anaesthesia.     Secure  in  the  stocks  with  the 
head  elevated,   a  rope  over   the   back   to  prevent   rearing, 


Fig.  13. 

Special  spraying  ecraser,  55  cm.  long. 


Fig.  14. 

Colin's  scalpel. 

straps  beneath  the  body  to  prevent  lying  down,  straps  or 
ropes  before  and  behind  the  animal  to  prevent  backward 
and  forward  movements,  all  four  feet  pinioned  to  the  floor, 
and  the  tail  firmly  secured  and  stretched  to  a  beam  above. 
Apply  a  bandage  to  the  tail  extending  for  a  distance  of  12 
to  15  inches  from  the  base  of  the  tail  in  order  to  secure  the 
tail  hairs  out  of  the  way  of  the  operator. 

With  soap,  water  and  brush  cleanse  the  tail,  perineum  and 
vulva  thoroughly,    being  especially  careful   to  remove  all 


VAGINAL  OVARIOTOMY  IN  THE  MARE. 


125 


detachable  masses  of  sebum  ;  50  per  cent,  alcohol  may  be 
used  sparingly  to  aid  in  removing  this.  Too  free  a  use  of 
alcohol  excoriates  the  delicate  skin.  Cleanse  the  clitoris 
carefully.  Follow  the  washing  with  a  free  application  of 
i:  1000  aqueous  sublimate  solution  to  the  external  parts  and 
for  a  short  distance  inside  the  vulvar  lips  and  to  the  clitoris. 
Do  not  introduce  irritant  disinfectants  into  the  healthy 
vagina  nor  deeply  into  the  vulva  as  it  may  cause  severe 
straining  during  and  subsequent  to  the  operation  and  b}'  in- 
juring the  vulvo- vaginal  mucosa  favor  subsequent  infection 
of  the  vaginal  wound. 

Wash  awaj'  the  sublimate  solution  with  a  tepid  0.6  per 
cent,  soda  bicarbonate  solution,  and  fill  the  vulvo-vaginal 
canal  with  the  same.  After  thorough  disinfection  of  the 
hands  and  arms  remove  the  disinfectants  by  washing  in 
sterile  soda  solution,  which  at  the  same  time  renders  the 
hand  unctuous  and  readily  introduced  through  the  vulva. 
Armed  with  the  guarded  sterilized  scalpel,  Fig.  14,  intro- 
duce the  right  hand  into  the  vagina  promptly  and  when  it 
is  well  "  ballooned  "  unsheath  the  knife  and  placing  it  just 
above  the  os  uteri  parallel  to  the  long  axis  of  the  uterus  and 
a  few  mm.  to  the  right  or  left  of  the  median  line  in  order  to 
avoid  a  loose  fold  of  mucous  membrane  generally  existing 
there,  the  blade  being  held  vertical,  that  is  the  cutting  sur- 
face parallel  to  the  longitudinal  muscular  fibers  of  the 
vagina,  and  guarding  the  possible  extent  of  its  introduction 
with  the  thumb  and  fingers,  push  it  directly  forward  in  a 
straight  line  with  a  quick  thrust  through  vaginal  mucosa, 
the  muscular  walls  and  the  peritoneum,  until  the  disap- 
pearance of  resistance  indicates  that  the  latter  has  been 
penetrated.     This  is  the  most  critical  step  in  the  operation. 

If  the  hand  is  introduced  into  the  vagina  immediately 
after  the  injection  of  the  sterile  saline  solution  the  vagina 
will  generall}'  be  found  "  ballooned  ''  or  will  quickly  become 
inflated  under  manual  movements.     If  the  solution  is  thrown 


126         VAGINAL  OJ'ARIOTOMY  IN  THE  MARE. 

out  the  vagina  may  collapse  and  closely  invest  the  hand,  in 
which  case  more  of  the  liquid  should  be  injected  when  it 
will  again  dilate.  If  the  hand  is  introduced  without  the 
knife,  withdrawn  and  then  introduced  with  it,  it  will  be 
frequently  found  that  the  vagina  has  collapsed  and  needs  a 
second  filling  with  the  fluid.  Patience  until  dilation  is 
accomplished  and  promptness  to  act  when  attained  are  prime 
requisites  to  success. 

The  knife  should  be  pushed  through  the  vagina  quickly 
making  a  clean  wound  the  width  of  the  blade,  when  the 
latter  is  to  be  withdrawn  and  laid  aside.  It  should  be  re- 
membered that  in  this  "ballooned"  state,  the  anterior 
wall  of  the  vagina  is  but  2  or  3  mm.  thick  and  easily  pene- 
trated. Introduce  the  hand  again,  push  one  finger  into  the 
incision,  then  a  second  and  third,  and  eventually  holding 
all  the  fingers  in  the  form  of  a  cone  push  the  entire  hand 
into  the  peritoneal  cavity.  Immediately  below  the  incision 
and  continuous  with  the  tissues  involved  in  the  wound  lies 
the  uterus  with  a  transverse  diameter  of  4  to  6  cm.  With 
the  palm  of  the  hand  downward,  trace  the  uterus  forward  a 
distance  of  15  to  18  cm.,  where  it  ends  abruptly  in  two 
cornua  of  about  the  same  size  as  the  body,  which  are  given 
off  horizontally  at  almost  right  angles.  Trace  these  to  the 
right  and  left  for  a  distance  of  14  or  15  cm.,  where  they 
end  obtusely,  and  3  or  4  cm.  beyond  this  in  a  direct  line, 
resting  upon  the  anterior  border  of  the  broad  ligament  is  the 
dense  oval  ovary  varying  in  size  from  2.5  to  7  cm.  in 
diameter. 

Prepare  the  ecraseur  for  use  by  withdrawing  the  chain 
until  the  loop  is  of  barely  sufficient  size  to  admit  of  its  being 
readily  slipped  over  the  ovary.  Grasp  this  loop  and  the  end 
of  the  ecraseur  tube  in  the  hand,  carry  the  instrument 
to  the  ovary  and  drop  the  loop  over  it  from  above.  Pass 
some  of  the  fingers  beneath  the  ovary  and  push  it  up 
through  the  chain  loop  and  grasp  it  there  with  the  thumb 


VA  GINAL  O  J  A  RIO  TOM  \ '  IN  THE  MA  RE.  1 2  7 

and  index  finger.  Holding  the  ovary  with  one  hand  tighten 
the  chain  quickly  with  the  other,  examine  to  make  sure 
that  a  loop  of  intestine  is  not  caught,  draw  the  ovary  well 
through  and  get  a  large  portion  of  the  oviduct,  and  crush 
off  promptly,  holding  to  the  gland  until  carried  out  through 
the  vulva.  Remove  the  other  ovary  in  the  same  way. 
Generally  it  is  most  convenient  to  remove  the  left  ovary 
with  the  right  hand  and  vice-versa  but  each  may  be  re- 
moved with  either  hand.  Wash  away  any  blood  from  the 
external  parts,  apply  sublimate  solution  freely  to  the  vulva, 
perineum  and  tail.  Keep  the  patient  quiet  for  five  or  six 
days,  and  feed  lightly  on  a  laxative  diet. 

II.  In  operating  under  anae.sthesia  the  animal  should  be 
cast  or  confined  upon  the  operating  table  in  lateral  re- 
cumbency preferably  with  the  posterior  part  of  the  body 
somewhat  higher  than  the  anterior  so  as  to  avoid  visceral 
pressure  in  the  pelvic  cavity.  Place  the  animal  under  com- 
plete anaesthesia.  Prepare  the  parts  in  the  same  manner 
as  already  described.  Carry  the  knife  into  the  vagina  in  the 
manner  previously  described  and  render  the  roof  of  that 
organ  tense  by  pushing  the  os  uteri  downward  and  forward 
with  the  hand  or  by  means  of  a  vaginal  tensor  or  speculum. 
It  is  important  that  the  vagina  be  held  well  down  toward 
the  floor  of  the  pelvis  so  as  to  carry  it  away  from  the  rectum, 
posterior  aorta  and  iliac  arteries  while  the  incision  is  being 
made.  The  incision  is  now  to  be  made  just  above  and  be- 
hind and  a  trifle  to  one  side  of  the  os  uteri  in  essentially  the 
same  manner  as  under  I,  except  that  when  the  vaginal 
tensor  is  used  the  cut  is  made  upward  and  backward  instead 
of  directly  forward.  The  remainder  of  the  operation  is 
identical  with  what  we  have  described  under  I.  Under 
anaesthesia  the  vagina  is  flaccid  and  can  not  be  made  to 
"  balloon." 


128  VAGINAL  OVARIOTOMY  IN  THE  MARE. 

DANGERS. 

Wounding  of  the  rectum  is  scarcely  possible  under  the 
first  method  if  care  is  taken  not  to  attempt  the  incision  until 
the  vagina  is  well  "ballooned,"  and  then  making  the  stab 
wound  directly  forward.  If  made  upwards  when  the  organ 
is  so  erected  the  accident  is  highly  probable,  and  with  the 
undilated  vagina  where  it  is  necessary  to  cut  upwards  the 
danger  is  ever  present.  Its  prevention  demands  that  in  the 
first  method,  the  operator  await  the  complete  "  ballooning  " 
and  then  make  his  incision  as  directed.  In  the  second 
method,  the  accident  is  to  be  prevented  by  being  careful  tO' 
push  the  vagina  down  away  from  the  rectum  and  hold  it 
away  while  the  incision  is  being  made.  If  the  wound  in  the 
rectum  passes  through  the  pelvic  connective  tissue  behind 
the  peritoneum  it  is  of  little  consequence,  but  the  operation 
should  be  abandoned  ;  if  the  bowel  is  opened  into  the 
peritoneal  cavity  the  accident  is  generally  fatal. 

Wounding  of  the  iliac  arteries,  which  generally  pro- 
duces prompt  death  from  hemorrhage,  results  from  the  in- 
cision being  made  upwards  instead  of  forwards  when  the 
vagina  is  "  ballooned  "  or  from  a  failure  to  hold  the  roof  of 
the  vagina  down  and  away  from  the  part  while  making  the 
incision  in  the  flaccid  organ  as  is  the  case  with  the  recumbent 
animal  under  anaesthesia.  It  is  most  likely  to  occur  with 
timid  operators  who  become  nervous,  especially  when  the 
vagina  does  not  "  balloon  "  promptly  or  the  mare  is  not  well 
secured.  The  accident  is  wholly  unnecessary  if  the  operator 
will  await  the  "  ballooning  "  in  the  first  operation  while  by 
the  second  method  it  is  prevented  by  proper  care  in  holding 
the  vagina  downward  and  forward  during  the  incision. 
When  it  has  occurred  it  is  generally  beyond  remedy  though 
in  some  cases  the  prompt  intravenous  injection  of  adrenaline 
chloride  may  stay  the  hemorrhage  and  save  life  of  the 
patient. 


VAGINAL  OVARIOTOMY  IN  THE  MARE. 


129 


Wounding  of  the  uterus  may  occur  when  the  incision  is 
directed  downward  and  may  greatly  embarrass  the  operator 
and  confuse  him  by  passing  the  hand  through  the  incision 
into  the  uterine  cavity.  It  is  to  be  avoided  in  the  first 
operation  (without  anaesthesia)  by  carefully  directing  the 
incision  straight  forwards.  When  the  accident  occurs  it  is 
of  little  consequence  beyond  the  embarrassment  and  may  be 
overcome  by  again  dilating  the  vagina  with  fresh  injections 
of  the  soda  solution  and  making  a  new  incision,  or  if  pre- 
ferred the  first  cut  may  be  corrected  by  placing  an  index 
finger  against  the  peritoneum  at  the  upper  part  of  the 
wound,  and  with  a  sudden  and  vigorous  thrust  break 
through  into  the  peritoneal  cavity,  or  the  error  may  be 
corrected  by  again  using  the  scalpel  and  directing  the  in- 
cision properly.  If  it  is  attempted  to  rupture  the  peritoneum 
with  the  finger  it  must  be  done  by  a  sharp  thrust  since 
otherwise  a  large  section  of  the  men)brane  will  be  pushed 
away  from  the  subjacent  tissues. 

Incomplete  penetration  of  the  vaginal  wall  is  liable  to 
occur  if  the  scalpel  is  dull  ox  the  vagina  imperfectly  "bal- 
looned "  and  flaccid,  or  if  the  operator  is  unduly  timid.  It 
is  best  prevented  by  avoiding  the  causes  as  related,  and 
once  it  has  occurred  it  is  generally  best  to  again  "balloon" 
the  organ  in  the  operation  without  anaesthesia  and  make  a 
new  incision  either  to  the  right  or  left  of  the  first.  It  may 
be  overcome  also  by  thrusting  the  index  finger  through  the 
peritoneum  as  described  in  the  preceding  paragraph  or 
completing  the  cut  with  the  scalpel. 

The  mistaking  of  a  ball  of  feces  for  the  ovary  has  oc- 
curred to  inexperienced  operators  and  the  fatal  error  of  re- 
moving the  portion  of  the  rectum  surrounding  the  fecal  pellet 
committed.  The  blunder  is  uncalled  for  ;  the  fecal  ball  is 
movable  in  the  bowel,  the  intestine  is  far  more  massive 
than  the  broad  ligament,  and  the  ovary  is  to  be  definitely 
identified  by  its  being  lodged  in  the  broad  ligament  just 
9 


I30 


I'AGINAL  OVARIOTOM)-  IN  THE  COW. 


beyond  the  end  of  the  cornua,  which  is  continuous  with  the 
uterus.  If,  therefore,  one  traces  the  uterus  forward  to  the 
cornua,  thence  along  each  of  these  to  their  extremities  and 
along  the  borders  of  the  broad  ligament  to  the  ovary,  as 
above  directed,  the  error  will  not  occur. 

The  incision  may  be  made  too  low  and  pass  beneath 
the  broad  ligament.  It  is  to  be  avoided  by  being  careful  to 
keep  close  to  the  median  line  and  above  the  os  uteri.  If  it 
occurs  the  operation  may  be  completed  from  beneath  with- 
out verj^  great  difficulty  only  that  the  ovary  now  lies  above 
the  hand  and  must  be  drawn  down  from  on  top  the  broad 
ligament  in  order  to  fix  the  ecraseur  upon  it. 

Infection  constitutes  always  the  most  serious  danger  and 
is  to  be  avoided  by  properly  securing  the  animal,  by  the 
avoidance  of  irritant  antiseptics  in  the  vagina,  by  rigid  anti- 
sepsis at  every  stage,  and  by  carrying  out  the  mechanical 
parts  of  the  operation  deliberately,  vigorously  and  neatly. 
If  infection  should  occur  it  will  generally  take  the  form  of 
pelvic  cellulitis  with  abscesses  and  rectal  stricture.  Enemas 
of  a  normal  salt  or  soda  solution  affords  the  surest  relief  of 
the  stricture  and  impaction  in  front  of  it.  The  abscesses 
must  be  watched  and  opened  early  into  the  vagina  or  rec- 
tum, and  the  case  treated  internally  and  locally  according 
to  general  surgical  principles. 


27.     VAGINAL  OVARIOTOMY  IN  THE  COW. 

Objects.  Increasing  the  fat-  or  milk-producing  qualities 
and  the  cure  of  nymphomania  or  other  ovarian  disease. 

Instruments.  Colin's  scalpel,  vaginal  dilator.  Miles' 
spaying  shears,  spaying  ecraseur. 

Technic.  Confine  the  cow  in  the  standing  position  in 
the  stocks,  secure  the  head  firmly  and  pass  two  boards  be- 
neath the  abdomen  and  sternum  to  prevent  lying  down,  and 
a  rope  over  the  middle  of  the  back  to  prevent  arching  of 
the  spinal  column  and  straining. 


VA GINAL  O  VARIO  TOM \ '  IN  THE  CO  W.  131 

Wash  and  disinfect  the  tail  and  the  perineum  and  flush 
out  the  vagina  with  a  0.5  per  cent,  solution  of  carbolic  acid 
or  lysol  at  a  temperature  of  about  100°  F.  Insert  the 
vaginal  dilator  with  one  hand  and  push  the  prolongation  at 
the  anterior  end  into  the  os  uteri.  With  the  other  hand 
elevate  the  handle  of  the  dilator  and  depress  and  push  for- 
ward the  uterus,  thus  rendering  the  roof  of  the  vagina  tense 
and  pushing  it  downward  away  from  the  rectum  Carry 
the  scalpel  into  the  vagina  with  the  right  hand  and  resting 
it  in  the  oval  of  the  dilator  make  an  incision  through  the 
roof  of  the  vagina,  beginning  at  a  point  8  to  10  cm.  posterior 
to  the  OS  uteri  and  extending  backward  on  the  median  line 
for  a  distance  of  2  or  3  cm.  Be  careful  to  make  the  incision 
entirely  through  the  mucosa,  muscle  and  peritoneum  at  the 
first  cut,  since  any  failure  to  complete  it  tends  to  cause  the 
peritoneum  to  separate  from  the  muscular  coat  and  form  a 
pocket  between  them,  while  the  serous  membrane  being 
very  elastic  renders  it  difficult  to  complete  the  incision. 
Introduce  two  fingers  through  the  incision,  and  reaching 
over  the  side  of  the  vagina  to  the  right  or  the  left,  the  right 
or  left  ovary  respectively  is  recognized  lying  immediately 
against  the  lower  part  of  the  vagina,  just  at  the  anterior 
border  of  the  pubis,  in  a  mass  consisting  of  the  cord-like 
Fallopian  tube  and  the  fimbrise  of  its  pavilion.  The  ovary 
may  be  distinguished  as  a  firm  oval  mass  2  to  4  cm.  in  length 
and  I  to  2  cm.  in  its  lesser  diameter  attached  to  the  broad 
ligament.  If  not  promptly  recognized  by  the  sense  of  touch, 
trace  the  vagina  and  uterus  forwards  with  the  fingers  from 
the  vaginal  incision  to  the  cornua  and  follow  them  as  they 
bend  forward  and  downward,  and  then  backward  and  up- 
ward to  the  oviducts,  until  the  ovary  is  reached  where  it  is 
attached  to  the  broad  ligament,  just  beyond  the  fimbriated 
end. 

Grasp  the  ovary  between  the  fingers  and  draw  it  through 
the  incision  into  the  vagina.  Introduce  the  scissors  or 
emasculator  with  the  other  hand,  and  when  the  ovary  is 


132 


\AGINAL  OJARIOrOMY  IN  THE  COW. 


reached  open  them  barely  sufficient  to  admit  the  ovarian 
attachments  between  the  blades  and  cut  the  gland  away 
along  with  a  portion  of  the  broad  ligament.  Or  introduce 
the  ecraseur  and  drawing  the  ovary  through  the  loop  of  the 
chain  and  holding  it  securely  until  the  instrument  is 
tightened,  crush  it  off  in  this  way. 

It  is  essential  that  plenty  of  the  broad  ligament  and  ovi- 
duct be  excised  with  the  ovary  to  insure  the  entire  removal 
of  the  latter,  because  the  accidental  leaving  of  the  smallest 
particle  of  ovarian  tissue  will  cause  a  development  of  this 
into  abnormally  large  cystic  ovisacs,  and  will  tend  to  in- 
crease instead  of  decrease  nymphomania.  Should  the 
animal  be  pregnant  the  ovary  on  the  gravid  side  is  dragged 
downward  and  forward  out  of  reach  of  the  operator's 
fingers,  and  if  it  is  desired  to  complete  the  operation  it  may 
be  necessary  to  enlarge  the  vaginal  wound  and  introduce 
the  entire  hand,  when  the  ovary  can  be  reached  and  re- 
moved.    Generally  no  after  care  is  necessary. 

The  Dangers  are  similar  to  those  of  the  mare.  The 
iliac  arteries  may  be  wounded  in  the  same  manner  as  in  the 
mare  and  is  preventable  by  being  careful  to  push  the  vaginal 
roof  well  downwards  away  from  the  rectum  and  sacrum. 
In  rare  instances  fatal  hemorrhage  follows  the  cutting  off 
of  the  ovaries  with  the  scissors  especially  in  cows  sterile  be- 
cause of  diseased  ovaries  accompanied  by  a  want  of  tone. 
For  this  reason  it  is  safer  in  cows  sterile  from  diseased 
ovaries  to  use  the  ecraseur  but  even  this  instrument  is  not 
wholly  proof  against  hemorrhage  and  fatalities  have  been 
rarely  recorded  after  its  use  so  that  some  veterinarians  have 
advised  ligation  of  the  arteries  instead,  but  this  is  a  complex 
process  which  requires  much  time  for  its  accomplishment. 
Another  danger  appears  in  the  presence  of  the  rumen,  the 
supero-posterior  portion  of  which  when  filled  with  food 
projects  into  the  pelvic  cavity  and  if  the  cut  is  directed  for- 
wards a  stab  wound  readily  penetrates  its  walls  with  fatal 
results.     Make  the  cut  upwards  and  backwards. 


OVARIOTOMY  IN  THE  COW  BY  THE  FLANK.     133 
28.     OVARIOTOMY  IN  THE  COW  BY  THE  FLANK. 

Instruments.  Clipping  shears,  convex  scalpel,  spaying 
shears,  or  ecraseur,  heavy  needle  and  thread. 

Uses,  Same  as  the  preceding,  applicable  to  heifers  or  to 
cows  in  which  the  vulva  is  too  small  to  admit  the  operator's 
hand  or  in  case  of  diseased  vagina  or  uterus. 

The  animal  may  be  secured  as  in  the  preceding  or  con- 
fined in  lateral  recumbency  with  the  hind  legs  extended 
backward  and  the  anterior  limbs  forward.  To  accomplish 
this  loop  a  rope  about  the  two  fore  feet,  another  about  the 
two  hind  feet,  and  drawing  upon  the.se,  cast  the  animal  and 
secure  it  in  recumbency  with  the  legs  extended  and  body 
stretched  by  fastening  the  ropes  to  two  strong  posts  about 
8  to  10  m.  apart.  The  operation  may  be  performed  in  either 
flank. 

Clip  the  hair  from  the  upper  part  of  the  flank,  disinfect 
an  area  15  to  25  cm.  square  and  make  an  incision  about  12 
cm.  long  beginning  at  a  point  equi-distant  from  the  anterior 
tuberosity  of  the  ilium,  the  ends  of  the  transverse  processes 
of  the  lumbar  vertebrae  and  the  last  rib  and  extend  it  down- 
wards perpendicularly  severing  the  skin  and  subcutaneous 
muscle.  Divide  the  external  oblique  muscle  in  the  direction 
of  its  fibres  by  means  of  the  scalpel  handle  or  the  fingers 
and  repeat  the  process  upon  the  internal  oblique  after  which 
puncture  the  peritoneum  with  the  scalpel.  Some  operators 
cut  directly  through  the  entire  abdominal  wall  at  a  single 
stroke,  but  this  comes  to  the  operator  only  by  experience. 

Force  one  hand  through  the  opening  into  the  peritoneal 
cavity  and  search  for  the  ovaries  at  the  same  point  and  by 
the  same  method  as  in  the  preceding  operation,  that  is, 
locate  the  uterus  within  the  pelvic  cavity,  between  the 
rectum  and  bladder  and  trace  it,  the  cornu,  and  broad 
ligament  to  the  ovary.  The  uppermost  ovary  can  be  drawn 
out  through  the  wound  and  cut  off  with  the  scissors  or 
ecraseur  ;  the  lower  one  must  be  held  with  one  hand  and 


134 


OVARIOTOMY  IN  THE  BITCH. 


the  instrument  introduced  along  the  arm  and  when  the 
ovary  is  reached,  apply  the  scissors  or  ecraseur  and  cut  or 
crush  it  off.  The  beginner  must  always  remember  that  the 
positive  means  for  identifying  the  ovaries  is  by  tracing  the 
uterus  from  the  vagina  along  its  cornua  to  the  oviduct  and 
thence  to  the  organ  in  the  broad  ligament.  Cleanse  the 
wound  and  close  the  skin  incision  with  continuous  sutures. 


29.     OVARIOTOMY  IN  THE  BITCH  BY  THE  FLANK. 
Plate  XX. 

Instruments.     Spaying  knife,  suture  material. 

Techic.  Confine  the  animal  in  lateral  recumbency, 
preferably  upon  the  right  side  for  a  right  handed  operator, 
the  head  somewhat  depressed,  the  limbs  extended  and  the 
body  well  stretched.  Clip,  shave  and  disinfect  a  sufficient 
area  in  the  exposed  flank  at  a  point  just  anterior  to  and  be- 
neath the  external  angle  of  the  ilium.  With  one  hand  grasp 
the  skin  fold  of  the  flank  and  render  the  skin  of  the  region 
tense,  while  with  the  other  holding  the  spaying  knife  like  a 
pen  make  at  first  a  drawing  incision  from  below  upward 
about  2  to  3  cm.  long,  ending  above  at  a  point  slightly  be- 
low the  external  angle  of  the  ilium,  the  incision  extending 
through  the  skin  and  subcutaneous  tissues  ;  without  remov- 
ing the  knife  from  the  wound  elevate  the  handle  and  with 
a  quick  thrust  make  a  stab  wound  extending  through  the 
external  and  internal  oblique  muscles  and  peritoneum  at  a 
single  cut.  The  operator  can  determine  when  the  peritoneal 
cavity  has  been  entered  by  the  disappearance  of  resistance. 

Introduce  an  index  finger  into  the  peritoneal  cavity,  and 
as  soon  as  this  has  been  entered  follow  directly  along  the 
peritoneum  upward  and  backward  toward  the  angle  of  the 
ilium  where  the  uterine  cornua  lie  covered  over  by  the 
broad   ligament.      The  internal   generative   organs  of  the 


OVARIOTOMY  IN  THE  BITCH. 


135 


bitch  are  unique  among  our  domesticated  animals.  The 
uterus,  U,  Plate  XX,  is  small  and  physiologically  unim- 
portant, the  cornua,  RUC  and  LUC,  are  ample  in  size  and 
constitute  physiologically  the  uterus.  The  distance  from 
the  cornual  extremity,  LUC,  to  the  ovary,  O,  which  is 
occupied  by  the  Fallopian  tube  is  very  brief  so  that  the 
cornua  and  ovary  are  well  nigh  in  contact.  The  ovary, 
O,  O,  is  very  small,  smooth  and  completely  hidden  in  the 
pavilion  which  here  constitutes  a  sac  having  a  very  small 
longitudinal  opening  of  2  to  5  mm.  The  most  remarkable 
feature  of  the  apparatus  from  a  surgical  standpoint  is  the 
great  development  of  the  broad  ligament  which  is  broader 
than  the  distance  from  the  lumbar  region  to  the  abdominal 
floor,  while  the  uterus  and  uterine  cornua  are  stretched 
between  the  vagina,  V,  and  the  ovary,  O,  so  that  they  are 
suspended  in  the  sub-lumbar  region  resulting  in  a  double 
fold  of  the  broad  ligament  hanging  down  like  a  curtain  be- 
tween the  parietal  peritoneum  and  the  uterus  and  cornua 
on  either  side.  The  broad  ligament  of  the  bitch  is  conse- 
quently suspended  at  one  point  from  the  sub-lumbar  region, 
at  the  other  from  the  uterus,  so  that  instead  of  that  organ 
being  suspended  by  the  ligament  the  relation  is  reversed 
and  the  ligament  is  suspended  from  the  uterus,  or  rather 
uterine  cornua. 

In  Plate  XX  the  right  broad  ligament,  BL',  is  laid  out 
upon  the  side  exposing  the  right  uterine  cornu,  RUC,  while 
on  the  left  side  the  ligament  is  divided  at  about  its  center 
and  the  posterior  portion,  BL',  is  laid  out  on  the  flank,, 
while  the  anterior,  BL,  is  left  in  its  normal  position  con- 
cealing a  portion  of  the  cornu,  LUC.  Unlike  our  other 
domesticated  animals,  the  broad  ligament  is  heavily  loaded 
with  fat  which  gives  it  an  appearance  very  similar  to  the 
omentum,  but  the  net-work  is  far  less  conspicuous  or  want- 
ing, the  omentum  also  extends  back  into  this  region  so  that 
the  two  are  in  contact. 


Plate  XX. 

Ovariotomy  in  the  Bitch. 

Abdomen  of  a  nou-preguant  bitch  Ij'ing  on 
the  back  with  the  abdominal  floor  removed  and 
the  onventiim  pushed  away.  TT,  the  two  pos- 
terior teats  ;  B,  bladder  ;  V,  vagina  ;  U,  uterus  ; 
LUC,  LUC,  left  uterine  cornua  with  a  portion 
of  its  broad  ligament,  BL,  lying  across  it ;  RUC, 
right  uterine  cornua  with  its  broad  ligament, 
BL'',  turned  outwards  exposing  the  full  length 
of  the  cornua.  On  the  left  side  the  ligament  is 
divided  so  that  the  anterior  half  rests  in  its  nor- 
mal position  while  the  posterior  half,  BL',  is 
turned  back.  0,0,  ovaries  ;  R,  rectum  ;  K,  left 
kidney  ;  AA,  a  line  indicating  the  level  of  the 
external  tuberosities  of  the  ilia. 


RUC- 


OVARIOTOMY  IN  THE  BITCH. 


139 


The  ovary  being  indistinct  and  hidden  is  difficult  to  iden- 
tify directly,  and  the  cornua  being  covered  over  by  the 
duplicature  of  the  broad  ligament  is  not  readily  reached, 
so  that  the  finger  generally  comes  in  contact  first  with  the 
broad  ligament  of  the  uppermost  cornu  hanging  loose  in 
the  peritoneal  cavity  :  engage  this  between  the  end  of  the 
finger  and  the  abdominal  wall  and  draw  it  out  through  the 
wound,  grasp  it  and  continue  drawing  upon  the  folds  of  the 
ligament,  especially  upon  the  median  or  under-most  portion 
until  the  naked  cornu  appears  through  the  opening,  seize 
it  and  draw  out  the  anterior  portion  until  the  ovary  follows, 
then  grasp  the  latter  with  the  thumb  and  index  finger  of 
one  hand  and  the  ovarian  ligament  with  the  same  members 
of  the  other  and  tear  the  ligament  through  between  them 
by  linear  tension.  Extend  the  tear  through  the  broad  liga- 
ment as  high  toward  its  lumbar  attachment  as  is  convenient 
and  backward  to  the  neighborhood  of  the  uterine  bifurca- 
tion. Draw  upon  the  exposed  coruu  until  the  point  of  bi- 
furcation appears,  when  the  other  branch  is  to  be  grasped 
and  drawn  out  through  the  opening.  In  young  puppies  the 
.securing  of  the  second  cornu  is  very  difficult  and  requires 
great  care  to  prevent  the  rupture  of  the  first.  The  object 
may  be  facilitated  by  pressing  the  upper  flank  of  the  bitch 
downward,  thereby  greatly  diminishing  the  transverse 
diameter  of  the  abdomen. 

The  succeeding  operation  (30)  avoids  this  difficulty  in  a 
large  measure.  Should  the  distal  cornu  be  ruptured  and 
with  its  ovary  drop  away  from  the  operator,  it  becomes  nec- 
essary to  turn  the  animal  over  and  make  a  second  incision 
on  the  opposite  side,  somewhat  further  forward.  When  the 
second  cornua  has  been  secured  draw  it  out  as  far  as  prac- 
ticable and  holding  it  tense  insert  an  index  finger  along  it 
until  the  ovary  is  reached,  which  is  recognized  by  its  slightly 
greater  size  and  density  succeeding  the  brief  neck  represent- 
ing the  Fallopian  tube  between  the  end  of  the  cornu  and 


I40 


OVARIOTOMY  IN  THE  BITCH. 


ovary,  while  beyond  it  can  be  felt  the  ovarian  ligament. 
Engage  the  ligament  between  the  end  of  the  index  finger 
and  the  abdominal  wall,  and  with  a  firm  and  vigorous  move- 
ment, using  the  finger  end  and  nail  as  a  curette,  rupture 
the  ovarian  ligament  by  drawing  the  finger  toward  the  in- 
cision, and  with  the  aid  of  tension  upon  the  cornu  draw  the 
ovary  out  through  the  abdominal  incision  and  divide  the 
broad  ligament  as  before.  Remove  the  cornua  with  the 
attached  ovaries  by  rupturing  them  transversely  near  the 
bifurcation  by  means  of  linear  tension. 

If  the  bitch  be  pregnant  and  especially  if  far  advanced 
the  uterine  cornua  will  lie  upon  the  abdominal  floor,  much 
enlarged  and  very  much  more  flaccid  than  the  nongravid 
uterus  and  feeling  very  much  like  intestines.  The  change 
in  the  position  of  the  uterus  has  caused  the  unfolding  of  the 
duplicature  of  the  broad  ligament  so  that  it  no  longer  covers 
the  cornu.  In  such  cases  the  operation  is  performed  in  the 
same  way  except  that  rupturing  the  blood  vessels  by  linear 
tension  does  not  insure  against  hemorrhage  and  it  is  neces- 
sary to  ligate  the  ovarian  and  uterine  arteries  with  catgut 
or  silk.  In  cases  of  pregnancy  the  entire  cornua  should  be 
drawn  out  and  a  strong  ligature  placed  around  the  uterus 
or  vagina,  and  the  ovaries,  uterine  cornua  and  their  con- 
tents be  removed  en  masse.  Release  the  upper  posterior 
limb  and  close  the  cutaneous  wound  by  a  continuous  suture. 

Dangers.  Rupture  of  the  uterine  cornu  alluded  to  above. 
It  is  always  to  be  remembered  that  the  leaving  of  one 
ovary  in  position  even  though  the  other  gland  with  the  two 
cornua  and  uterus  are  removed,  induces  intense  oestrum 
and  renders  the  animal  if  anything  more  disagreeable  than 
before  the  operation. 

The  ureter  may  be  mistaken  for  the  cornu  but  is  smaller, 
is  closely  attached  to  the  abdominal  walls,  and  does  not 
have  the  broad  ligament  with  its  large  deposit  of  fat.  The 
kidney  is  far  larger  than  the  ovary,  more  exposed,  and 
located  more  anteriorly. 


OVARIOTOMY  IN  THE  BITCH. 


141 


The  iliac  arteries  are  at  times  caught  and  ruptured  by 
the  finger  but  the  blunder  is  uncalled  for  except  through 
nervousness  of  the  operator. 

Instances  of  puncturing  the  bladder  in  making  the  in- 
cision have  been  reported.  If  the  bitch  has  been  led  out 
and  caused  to  urinate  prior  to  operating,  the  accident  is 
made  practically  impossible. 


30.     OVARIOTOMY  IN  THE  BITCH  BY  THE  LINEA  ALBA. 
Plate  XX. 

Instruments.     Same  as  in  the  preceding. 

Technic.  Confine  in  the  dorsal  position  with  the  head 
sharply  declined.  Shave  and  disinfect  an  area  on  the  median 
line  about  6  cm.  square  extending  forward  from  the  pubic 
brim.  Make  an  incision  on  the  median  line  about  4  cm. 
long  beginning  just  in  front  of  the  pubic  brim  and  extend- 
ing forward  cutting  entirely  through  the  skin,  the  linea 
alba  and  peritoneum.  Insert  an  index  finger  and  identify 
the  uterus  or  broad  ligament  by  its  location  and  form. 
The  finger  usually  comes  in  contact  first  with  the  urinary 
bladder  which  may  more  or  less  obstruct  the  passage  to  the 
uterus  according  to  its  degree  of  distension.  When  empty 
as  shown  at  B,  it  offers  practically  no  obstruction.  When 
very  much  distended  it  may  be  evacuated  by  gentle  pressure 
with  the  fingers.  The  operator  should  be  careful  not  to 
draw  the  bladder  out  through  the  incision  as  its  replace- 
ment may  prove  difficult  and  its  puncture  with  a  hypo- 
dermic needle  or  an  enlargement  of  the  abdominal  incision 
may  be  necessary  in  order  to  bring  about  its  return.  Push 
the  bladder  aside  if  necessary  and  just  above  it  and  below  the 
rectum  the  uterus  should  be  readily  distinguished  and  either 
it  or  the  broad  ligament  caught  by  the  finger  and  brought 
out  through  the  incision  after  which  the  operation  proceeds 


142 


OVARIOTOMY  IN  THE  CAT 


in  the  same  manner  as  by  the  flank  method.  By  passing  an 
index  finger  forward  to  reach  the  lower  surface  of  the  rec- 
tum in  front  of  the  uterus  and  then  drawing  it  backwards 
the  finger  passes  between  the  former  and  the  cornua  and 
the  latter  are  picked  up.  It  has  a  distinct  advantage  over 
the  flank  method  in  that  in  puppies  there  is  not  so  much 
difficulty  in  bringing  out  the  ovaries,  nor  the  danger  of  the 
rupture  of  the  cornua  and  the  ovary  being  retained. 

By  the  use  of  retractors  in  the  abdominal  incision  the 
operator  is  enabled  to  see  the  uterus  in  position  and  grasp  it 
by  means  of  forceps,  obviating  the  necessity  for  introducing 
the  finger  into  the  peritoneal  cavity. 

The  sutures  must  extend  entirely  through  the  abdominal 
wall  and  be  carefully  placed  in  order  to  prevent  hernia. 
Interrupted  sutures  are  preferable.  If  the  operation  has 
been  properly  performed  no  bandage  is  necessary  and  the 
patient  will  not  disturb  the  sutures.  If  asepsis  has  not  been 
strictly  followed  infection  may  occur  and  the  consequent 
irritation  cause  the  patient  to  tear  the  sutures  out,  which 
may  lead  to  protrusion  of  the  intestines  or  other  abdominal 
viscera.  If  the  sutures  do  not  include  the  deeper  layers  of 
the  abdominal  wall  hernia  is  liable  to  occur  and  require  a 
second  operation. 


31.    OVARIOTOMY  IN  THE  CAT. 

Instruments.     Same  as  for  the  bitch. 

Technic.  The  cat  may  be  spayed  by  either  the  flank 
method  or  through  the  linea  alba.  The  point  of  incision  in 
either  case  is  the  same  as  in  the  bitch  but  owing  to  the 
smaller  size  of  the  animal  it  is  necessary  to  make  the  wound 
quite  small.  The  abundance  of  fur  renders  it  essential 
that  an  ample  area  be  shaved  and  the  surrounding  hair  be 
saturated   with  a  disinfectant  and  carefully   brushed  away 


CASTRA TION  OF  CRYPTORCHID  HORSES.        143 

from  the  operative  area.  The  cat  being  more  subject  to 
infection  than  the  bitch  the  aseptic  precautions  must  be  of 
the  strictest  possible  character.  The  operative  area  must 
be  thoroughly  disinfected  and  cleansed  and  equal  care  must 
be  taken  not  to  introduce  irritant  disinfectants  into  the 
wound.  A  great  danger  also  exists  in  the  tendency  of  the 
muscle  layers  of  the  abdomen  to  readily  become  separated  by 
pressure  from  the  finger  and  form  a  pocket  in  which  wound 
discharges  accumulate  and  constitute  a  dangerous  seat  for 
infection.  Great  care  must  therefore  be  taken  to  make  a 
clean  incision  directly  into  the  peritoneal  cavity  and  to 
avoid  separating  the  peritoneum  from  the  muscles  or  the 
muscular  layers  from  each  other.  The  uterus  and  ovaries 
of  the  cat  are  naked  and  far  more  easily  distinguished  than 
in  the  bitch,  there  being  no  extra  deposit  of  fat  in  the  broad 
ligament.  The  sutures  are  to  be  applied  to  the  wound  in 
the  same  manner  as  in  the  bitch. 


32.    CASTRATION  OF  CRYPTORCHID  HORSES. 
Plates  XXI  and  XXII. 

Instruments.     Scalpel,  emasculator. 

Technic.  Confine  the  animal  by  casting  in  the  dorsal 
position  with  the  hocks  well  flexed  and  both  posterior 
limbs  completely  abducted  so  as  to  fully  expose  the  inguinal 
region.  Or  secure  upon  the  operating  table  on  the  side 
oppo.site  to  the  retained  gland  and  abduct  the  upper  pos- 
terior limb  by  drawing  it  upward  by  means  of  a  pulley. 
Cleanse  and  disinfect  the  inguinal  region.  Anaesthize. 
Make  an  incision  about  10  to  12  cm.  long  through  the  skin 
and  dartos  directly  over  the  normal  position  of  the  scrotum, 
parallel  to  the  median  raphe  about  4  or  5  cm.  distant  from 
it.  Insert  the  two  index  fingers  in  the  wound,  press 
them  into  the  areolar  tissue  toward  the  external  inguinal 


144 


CAS7 /NATION  OF  CRYPTORCHID  HORSES. 


ring  and  drawing  them  apart  separate  the  tissues 
sufficiently  to  permit  the  entrance  of  the  hand.  With  the 
fingers  held  in  the  shape  of  a  cone  bore  a  passage  in  the 
areolar  tissue  through  the  external  abdominal  ring  and  con- 
tinue in  a  direction  approximately  toward  the  external 
angle  of  the  ilium  until  the  aponerosis  of  the  small  oblique 
muscle  near  the  crural  arch  is  reached.  Unless  rectal  ex- 
ploration has  shown  that  the  testicleis  within  the  abdomen, 
take  care  in  traversing  the  inguinal  space  between  the  ex- 
ternal and  internal  rings  that  the  gland  is  not  passed  by 
unrecognized  (inguinal  cryptorchidy)  lying  in  this  region 
covered  by  peritoneum  and  the  cremasteric  fascia.  Some- 
times the  epididymis  has  descended  to  the  scrotal  region 
while  the  testicle  remains  within  the  abdomen,  thus  result- 
ing in  a  long,  narrow  inguinal  canal. 

Pass  the  hand  upwards,  outwards  and  forwards  along  the 
aponeurosis  of  the  small  oblique  until  the  crural  arch  is 
reached  slightly  anterior  to  the  crural  ring  in  which  the 
pulsating  femoral  artery  can  be  felt,  and  palpate  at  this  point 
in  the  muscular  wall  for  the  internal  inguinal  ring  which 
varies  greatly  in  different  individuals  but  usually  reveals 
itself  to  the  fingers  as  an  oblong  slit  or  ring  about  one  inch 
in  length  covered  only  by  peritoneum.  Through  this  usually 
extends  a  portion  of  the  gubernaculum  testis  or  of  the  vas 
deferens. 

Examing  Plate  XXI,  the  peritoneal  view  of  the  internal 
ring  is  shown  crossed  by  the  dotted  line,  V,  of  the  upper  or 
right  testicle,  into  which  extends  a  short  distance  the  tail 
of  the  epididymis.  In  the  lower  or  left  testicle  the  ring 
has  been  opened  and  the  gland  lies  in  a  position  correspond- 
ing to  the  right  and  showing  the  epididymis  and  vas  defer- 
ens lying  in  the  processus  vaginalis,  P.  The  surgical  rela- 
tion of  the  parts  is  further  illustrated  in  Plate  XXII,  where 
the  testicle  is  completel}^  withdrawn  into  the  peritoneal 
cavity  and  spread  out  over  the  right  flank.     The  processus 


CASTRATION  OF  CRYPTORCHID  HORSES. 


145 


vaginalis,  P,  is  outlined  by  a  dotted  line  into  which  is  in- 
troduced a  curved  sound,  S,  along  side  of  which  lies  the 
gubernaculum,  G.  The  gubernaculum,  it  will  be  observed 
is  divisible  into  three  sections,  a  slender  one,  G,  which  by 
passing  along  behind  the  peritoneum  escapes  from  the 
abdominal  cavity  at  the  postero-external  commissure  of  the 
ring  to  extend  to  the  scrotum.  The  second  portion  of  this 
organ,  G',  is  much  thicker  and  extends  from  G  to  the 
epididymis  at  E,  while  the  third  division,  G",  extends  from 
the  epididymis  to  the  testicle. 

In  Plate  XXII  it  is  shown  that  the  testicle  under  all  ordi- 
nary conditions  is  inevitably  attached  through  its  guber- 
naculum testis  to  the  postero-external  commissure  of  the 
ring  and  that  it  has  a  second  definite  attachment  to  the 
seminal  bladder  through  the  medium  of  the  vas  deferens,  V, 
and  a  third  by  means  of  the  testicular  artery,  A.  The 
gubernaculum  and  the  vas  deferens  constitute  the  essential 
guides  in  locating  and  recognizing  the  testicle. 

By  forming  a  hollow  cone  with  the  fingers  about  the  in- 
ternal ring,  the  vas  deferens,  epididymis  and  gubernaculum 
tend  to  drop  out  into  the  processus  vaginalis  where  they 
may  be  grasped  with  the  fingers  without  the  peritoneum 
having  been  ruptured.  The  vas  deferens  and  epididymis 
present  characteristics  which  are  unmistakable  to  the 
trained  touch  consisting  of  a  small  firm  cord  (vas  deferens) 
or  a  small  mass  of  fine  threads  (tail  of  epididymis)  which 
roll  freely  between  the  thumb  and  finger  and  give  a  sensa- 
tion which  is  unlike  that  produced  by  any  other  tissue  in 
the  body. 

Grasp  the  part  firmly  and  tearing  through  the  peritoneum 
seize  the  vas  deferens  and  carefully  draw  it  out  through  the 
external  wound.  (In  teaching  cryptorchid  castration  to 
the  beginner  we  make  our  opening  down  to  the  internal 
ring  and  grasp  the  vas  deferens  between  the  thumb  and 
finger  without  penetrating  the  peritioneal  cavity  and  then 
10 


Plate  XXI. 

Castration  of  Cryptorchid  Horse. 

Urino  genital  apparatus  of  24  hr.  colt.  T,  T. 
testicle  ;  A,  testicular  artery  ;  G,  gubernaculum 
testis  ;  V,  V,  vas  deferens  ;  B,  urinary  bladder  ; 
UA,  umbilical  arteries  retracted  within  abdomen  ; 
P,  processus  vaginalis  ;  UV,  umbilical  vein. 


CASTRATION  OF  CRYPTORCHID  HORSES.         149 

passing  a  pair  of  long  uterine  dressing  forceps  along  the 
hand,  fasten  them  upon  the  vas  deferens.  The  student 
then  completes  the  operation,  using  the  forceps  as  a  guide. 
He  thus  learns  the  relations  and  character  of  the  parts 
and  recognizes  the  internal  ring  with  the  peritoneum  still 
stretched  across  it,  intact.) 

In  case  the  vas  deferens  can  not  be  felt  before  rupturing  the 
peritoneum,  it  may  be  broken  through  with  the  index  finger 
and  inserting  the  finger  into  the  cavity,  the  gubernaculum 
is  found  attached  to  the  postero-external  border  of  the  ring, 
and  but  a  short  distance  therefrom  the  finger  comes  in  con- 
tact with  the  vas  deferens  or  with  the  tail  of  the  epididymis 
where  the  gubernaculum  crosses  it  at  E,  in  Plate  XXII. 
Having  reached  the  vas  deferens  the  operation  is  proceeded 
with  as  above.  Thus  far  the  operator  has  not  concerned 
himself  with  the  location  of  the  testicle  but  relies  wholly 
upon  the  vas  deferens  or  gubernaculum,  since  when  either 
of  these  is  recognized  the  testicle  is  virtually  within  his 
power. 

He  thus  proceeds  upon  the  basis  that  he  is  not  \.o  find  \.\\^ 
testicle  for  the  reason  that  it  is  not  lost  but  that  it  has  de- 
finite relations  and  attachments  which  permit  of  certain 
displacements  of  the  organ  itself  but  not  of  its  attachments. 

Having  drawn  the  vas  deferens  out  through  the  wound 
tension  is  exerted  upon  it  which  tends  to  cause  the  testicle 
to  follow  but  sometimes  the  gland  is  too  large  to  pass  the 
internal  ring  and  the  latter  needs  be  dilated  by  inserting 
an  index  finger  in  it  or  the  testicle  needs  be  guided 
through  the  opening. 

We  have  described  herein  one  method  of  castrating  a 
cryptorchid  horse  where  the  cryptorchidy  is  due  to  an  arrest 
in  the  development  of  the  gland  and  of  its  descent.  There 
are  other  methods  employed  which  introduce  variations  at 
each  step,  many  operators  making  the  incision  over  the 
external   ring    instead    of   near   the   median   line.      Other 


Plate  XXII. 

Castration  of  Cryptorchid  Horse. 

Right  inguinal  region  and  testicle  of  24  lirs.  colt.  P,  processus 
vaginalis  surrounded  by  a  dotted  line  and  containing  a  curved  sound, 
vS  ;  G,  first  portion  of  gubernaculuin  testis  ;  G',  second  portion  of  gul)- 
ernaculum  testis  extending  to  the  epididymis,  E  ;  E,  epididymis  ; 
Q'\  gubernaculum  extending  from  epididymis  (globus  minor)  to  the 
testicle  ;  T,  testicle  ;  A,  testicular  artery  ;  V,  V,  vasa  deferentia ;  B, 
uriuarv  bladder  ;  UA,  um1)ilical  arteries. 


m 


^ 


to 


/'■ 


QQ 


\   / 
V 


CASTRATION  OF  CRYPTORCHID  HORSES.         153 

operators  avoid  opening  the  internal  ring  and  penetrate  the 
peritoneal  cavity  somewhat  in  front  of  and  above  the  ring 
through  the  small  oblique  muscle.  When  one  plan  has 
been  learned  the  variations  are  easil}'  applied. 

There  are  other  causes  of  cryptorchidy  which  in  rare  cases 
require  a  different  procedure  in  order  to  extract  the  gland 
varying  with  individual  cases  but  the  essentials  for  the 
tracing  and  recognition  of  the  testicle  are  the  same. 

Prior  to  attempting  the  operation  it  is  well  to  make  a 
rectal  exploration  and  determine  as  far  as  may  be  the  loca- 
tion of  the  testicle,  whether  it  be  on  the  right  or  left  side, 
and  its  character,  should  it  be  in  any  way  pathologic. 

After  the  testicle  is  brought  to  the  surface  it  may  be  re- 
moved with  the  emasculator  or  by  such  means  as  the  opera- 
tor may  prefer.  Cryptorchid  testicles  when  due  to  arrest 
in  development  are  not  vascular  and  there  is  little  tendency 
to  hemorrhage  after  exci.sion.  Place  an  antiseptic  tampon 
in  the  wound,  pushing  it  well  up  against  the  internal  ring 
and  retain  it  in  position  by  means  of  sutures  for  a  period  of 
24  to  48  hours  when  it  is  removed  and  the  wound  dressed 
antiseptically. 

The  operation  for  cryptorchidy  in  the  smaller  animals  is 
essentially  the  same  as  in  the  horse  except  that  the  incision 
is  to  be  made  ordinarily  through  the  flank  as  in  spaying. 
The  same  attachments  are  to  be  our  guide  and  the  operation 
is  to  proceed  upon  almost  parallel  lines. 


IV.  OPERATIONS  ON  THE  EXTREMITIES. 

33.    TENOTOMY  OF  THE  FLEXORS  OF  THE  PHALANGES. 
Plate  XXIII. 

Objects.  The  relief  of  contraction  of  the  flexor  tendons 
of  the  foot. 

Instruments.  Razor,  scissors,  sharp  tenotome,  bandage 
material. 

Technic.  Tenotomy  is  generally  performed  on  the 
flexor  of  the  third  phalanx,  seldom  on  the  superficial  flexor 
or  flexor  of  the  .second  phalanx. 

Confine  upon  the  operating  table  with  the  affected 
member  undermost  and  the  foot  fully  extended.  In  default 
of  a  table  confine  in  lateral  recumbency  and  apply  an  exten- 
sion splint  to  the  foot  as  shown  in  Plate  XXIII. 

On  the  median  side  at  the  middle  of  the  metacarpus  or 
metatarsus  the  skin  is  shaved  and  disinfected  over  the 
tendon  of  the  flexor  pedis  muscle.  The  location  named  lies 
between  the  lower  extremity  of  the  great  carpal  or  tarsal 
sheath  above  and  the  superior  extremity  of  the  tendonous 
sheath  of  the  fetlock  below,  .so  that  neither  of  these  is 
wounded  during  the  operation,  but  the  tendon  is  severed  at 
a  point  where  it  is  invested  by  loose  connective  tissue  which 
retains  the  divided  ends  in  their  normal  line  of  direction, 
somewhat  fixed,  and  favors  their  ultimate  leunion. 

Grasp  the  metacarpus  or  metatarsus  in  this  area  from 
above  and  behind  in  such  a  manner  that  the  thumb  rests 
upon  the  median  or  upper  surface,  and  the  index  and  second 
fingers  on  the  lateral  or  under  side  of  the  flexor  pedis 
tendon.  While  the  left  thumb  pushes  the  skin  toward  the 
bone,  that  is,  forward,  a  sharp  pointed  tenotome  held  perpen- 
dicularly in  the  right  hand  is  introduced  with  the  cutting 
edge  toward  the  hoof  through  the  skin,  subcutem  and  anti- 
brachial  fascia  down  to  the  flexor  pedis  tendon.     Immedi- 


4  -  - 

1    5  ^ 


U    .2 


o     o 
5    P 


156         TENOTOMY  OF  FEXORS  OF  PHALANGES. 

ateh'  on  the  anterior  border  of  the  tendon  insert  the  teno- 
tome so  far  that  the  point  of  it  can  be  felt  on  the  lateral  or 
outer  side  through  the  skin  with  the  left  hand. 

Care  is  to  be  exercised  in  making  this  invading  incision 
to  not  include  the  metacarpal,  or  metatarsal,  arteries,  veins 
and  nerves.  The  vascular  bundle  lying  immediately  against 
the  anterior  border  of  the  flexor  of  the  third  phalanx,  it  is 
easy  to  err  by  inserting  the  tenotome  in  front  of  the  vessels, 
that  is  between  the  suspensory  ligament  and  vessels  instead 
of  between  the  flexor  of  the  third  phalanx  and  vessels.  It 
is  safer  to  make  the  skin  incision  far  enough  posteriorly  to 
insure  safety  to  the  vessels,  cut  down  upon  the  tendon,  then 
incline  the  handle  of  the  tenotome  backwards,  push  the 
point  of  the  tenotome  obliquely  forward  and  downward 
behind  and  beneath  the  vascular  bundle  and  then  carrying 
the  handle  forward  bring  the  instrument  to  a  perpendicular 
position  while  it  is  forced  down  along  the  anterior  surface 
of  the  tendon  until  it  nears  the  inferior  border  when  the 
tenotome  handle  should  be  carried  yet  further  forward  so 
that  the  point  is  directed  obliquely  backward,  to  facilitate 
its  passing  between  the  vessel  bundle  and  the  tendon  out  to 
the  skin.  The  invading  incision  thus  describes  the  segment 
of  a  circle,  with  its  concavit}^  backward  toward  the  tendon. 

The  cutting  edge  of  the  instrument  is  then  turned  against 
the  tendon,  that  is,  it  is  directed  backward,  the  foot  is  ex- 
tended by  an  assistant  with  the  aid  of  a  rope  bound  around 
the  pastern  and  looped  over  the  hoof,  and  the  tendon  is  cut 
through  under  light  pressure,  the  operator  pressing  the 
handle  of  the  knife  forward  and  downward,  using  the  meta- 
carpus or  suspensory  ligament  as  a  fulcrum  upon  w^hich  the 
back  of  the  tenotome  rests  as  a  lever.  A  loud  cracking,  as 
well  as  the  disappearance  of  resistance  to  extension  shows 
that  the  tendon  has  been  severed. 

After  the  removal  of  the  knife  and  seeing  that  there  is  a 
wide  space  between  the  ends  of  the  tendon,  the  foot  is  un- 


PERONEAL    TENOTOMY 


157 


bound  from  the  splint  and  a  bandage  applied  to  the  meta- 
carpus, which  rests  upon  the  fetlock  joint  and  remains  in 
position  for  eight  days.  Healing  of  the  cutaneous  wound 
by  primary  union. 


34.    PERONEAL  TENOTOMY. 
Plate  XXIV. 

Object.     The  relief  of  Stringhalt. 

Instruments.     Razor,  scissors,  sharp  tenotome. 

Technic.  On  the  lateral  side  of  the  metatarsus  a  triangle, 
d,  opening  toward  the  tarsus  is  formed  by  the  tendons  of  the 
extensor  pedis  longus  muscle,  /,  and  the  lateral  extensor  of 
the  foot,  e,  which  unite  on  the  anterior  surface  of  the  middle 
of  the  metatarsus.  The  synovial  sheath  of  the  extensor 
pedis  longus  muscle  extends  inferiorly  to  near  the  point  of 
juncture  of  the  two  tendons  ;  the  sheath  of  the  lateral  ex- 
tensor ends  below  3  to  4  cm.  above  the  point  of  union.  In 
the  middle  of  this  space  without  a  sheath,  which  is  3  to  4 
cm.  long,  and  below  the  annular  ligament  of  the  hock  the 
operation  is  carried  out.  After  the  skin  has  been  shaved 
and  disinfected,  confine  in  the  stocks  or  operate  upon  the 
standing  horse,  with  the  aid  of  local  anaesthesia,  a  twitch 
being  applied  to  the  nose  and  the  opposite  hind  foot  held  up 
with  the  side-line.  The  tendon  of  the  lateral  extensor  is 
easily  felt  under  the  skin  as  a  hard  cord  about  0.7  to  i  cm.  in 
diameter.  Stretch  the  skin  and  with  the  back  of  the  hand 
toward  the  hock  grasp  and  compress  the  tendon  with  the 
thumb  and  index  finger  of  one  hand,  insert  the  tenotome 
with  the  cutting  edge  toward  the  foot  perpendicularly  upon 
the  tendon  through  the  skin,  subcutem  and  aponeurosis 
derived  from  the  crural  fascia  ;  push  it  from  before  back- 
ward under  the  tendon,  turn  the  cutting  edge  against  it, 
and  with  the  hock  extended  sever  the  tendon  as  well  as  the 


Plate  XXIV. 

Peroneal  Tenotomy  for  Stringhalt. 

Right  hind  foot  seen  from  the  external  side. 
The  skin  covering  the  lateral  extensor  of  the 
foot  is  laid  back  in  the  form  of  a  flap,  the  crural 
fascia  divided.  e,  Peroneal  tendon ;  /,  crural 
fascia  ;  /,  tendon  of  the  anterior  extensor  pedis 
muscle  ;  d,  the  triangle  formed  by  /  and  e. 


CUNEAN  TENOTOMY. 


159 


fascia  through  to  the  skin.  In  accomplishing  the  section 
of  the  tendon  the  knife  is  to  be  used  as  a  lever  of  the  first 
class  with  the  anterior  border  of  the  metatarsus  acting  as  a 
fulcrum.  If  the  tendon  has  been  completely  severed  its 
retracted  ends  may  be  felt  under  the  skin  i  to  2  cm.  above 
and  below  the  wound.  After  the  operation  an  antiseptic 
bandage  is  applied,  resting  upon  the  fetlock.  The  bandage 
should  remain  eight  days  and  the  cutaneous  wound  heal  by 
first  intention.  Care  should  be  taken  to  not  wound  the 
tendon  of  the  extenson  pedis  longus  muscle. 

Recently  it  has  been  proposed  to  permanently  obliterate 
the  function  of  the  peroneus  muscle  by  severing  its  tendon 
within  its  tarsal  sheath  above  and  below  the  tarsus  and 
withdraw  the  isolated  section.  The  same  object  may  be 
attained  by  merely  severing  the  tendon  within  its  sheath 
below  the  tarsus,  if  the  operation  is  carried  out  under  aseptic 
precautions  because  when  thus  performed  the  epithelium 
advances  over  the  retracted  cut  ends  and  leaves  them  free 
in  the  sheath. 


35.     CUNEAN  TENOTOMY. 
Plate  XXV. 

Object.     The  relief  of  spavin  lameness. 

Instruments.  Razor,  scissors,  straight  scalpel,  Peters' 
spavin  knife. 

Technic.  Most  horses  can  be  operated  on  standing,  with 
the  aid  of  cocaine,  otherwise  cast,  or  secure  on  the  operat- 
ing table,  on  the  affected  side  and  extend  the  tarsus.  Shave 
and  disinfect  an  area  5  to  6  cm,  square  on  the  inferior  median 
surface  of  the  hock  over  the  course  of  the  cunean  tendon  of 
the  chief  flexor  of  the  metatarsus,  as  indicated  in  Plate 
XXV.  Locate  the  tendon,  CT,  by  palpation  as  it  passes 
obliquely  downward  and  backward  and  make  a  transverse 
incision  with  a  straight  scalpel  or  tenotome,  in  the  form  of 


Plate  XXV. 


Cunean    Tenotomy. 


For    the     relief 
cunean    tendon. 
ergot. 


of    spavin     lameness.        CT, 
The   dotted   line   crosses   the 


NEUROTOMY.  i6i 

a  stab  wound,  merely  sufficient  lo  afford  passage  for  the 
blade  of  the  instrument,  about  i  cm.  below  its  inferior  border 
at  a  point  midway  between  the  anterior  and  posterior  borders 
of  the  hock,  or  slightly  anterior  theretp.  Push  the  tenotome 
flatwise  between  the  skin  and  tendon,  as  shown  in  the  plate, 
force  it  upwards  to  the  superior  border  of  the  tendon, 
then  turn  the  cutting  edge  toward  it  and  elevating  the 
handle,  using  the  superior  border  of  the  skin  wound  as  a 
fulcrum,  cut  the  tendon  through  from  without  inwards. 
By  firm  pressure  upon  the  skin  over  the  tenotome  peri- 
osteotomy is  simultaneously  accomplished.  The  completion 
of  the  operation  is  evidenced  by  the  separation  of  the  cut 
ends  of  the  tendon  leaving  a  well-marked  depression  at  the 
point  of  division.  Disinfect  the  wound,  apply  an  antiseptic 
tarred  bandage  resting  upon  the  fetlock  and  including  the 
hock  and  allow  to  remain  undisturbed  for  six  days.  Healing 
by  primary  union.  After  the  incision  through  the  skin  has 
been  made,  the  Peters'  knife  may  be  used  instead  of  the 
straight  scalpel,  and  the  tendon  and  periosteum  cut  through 
at  two  or  three  different  points,  the  cuts  diverging  upwards 
from  the  cutaneous  wound,  V-shaped. 


NEUROTOMY. 


General  Remarks.  Neurotomy  is  performed  for  a  vari- 
ety of  objects,  such  as  the  relief  of  pain  in  a  sensitive  nerve 
itself,  as  in  trifacial  neurotomy,  p.  64,  the  relief  of  pain, 
or  lameness  in  a  part  supplied  by  a  sensory  nerve,  or  the 
inhibition  of  motor  power,  as  in  the  "cribbing"  opera- 
tion by  severing  the  spinal  accessory  where  it  passes  intO' 
the  sterno-maxillaris  muscle. 

The  following  neurotomies  are  designed  to  relieve  pain 
and  the  consequent  lameness  dependent  upon  a  pathologic 
condition  of  some  part  or  tissue  on  the  distal  side  of  the 
II 


J  62  NEUROTOMY. 

point  of  operation  and  to  which  the  divided  sensory  nerve 
is  destined. 

Neurotomy  of  a  sensory  nerve  is  always  a  painful  opera- 
tion, and  its  performance  without  anaesthesia  is  unjustifiable 
from  a  humane  standpoint,  and  cannot  be  so  well  done  either 
from  the  view  of  mechanical  correctness  or  the  carrying  out 
of  antiseptic  standards.  Some  neurotomies  can  be  well  per- 
formed on  the  standing  animal  if  it  is  quiet  and  the  operator 
is  experienced,  the  parts  being  rendered  insensitive  b)'^ 
means  of  cocaine  or  other  local  anaesthetic  ;  in  the  greater 
neurotomies  general  anaesthesia  may  be  desirable  or  neces- 
sary from  the  humane  or  operative  standpoint. 

The  confinement  of  animals  for  neurotomy  on  the  sensory 
nerves  of  the  extremities  for  the  relief  of  lameness  is  always 
to  be  viewed  as  a  critical  procedure  for  the  reason  that  the 
operation  is  generally  made  because  of  the  local  manifesta- 
tion of  a  more  or  less  general  disease  which  may  be  accom- 
panied by  general  fragility  of  the  skeleton,  and  as  a  result 
most  casting  accidents  occur  in  cases  of  confining  for 
neurotomy  or  firing  in  cases  of  lameness  belonging  to  the 
great  group  of  dry  arthritis  or  spavin  family.  Casting  must, 
therefore,  be  done  with  the  greatest  possible  care,  and  the 
operating  table  is  to  be  constantly  and  greatly  preferred. 

Neurotomy  is  properly  a  last  resort  in  lameness  and  should 
not  otherwise  be  performed.  It  has  two  great  and  ever 
present  dangers.  If  the  part  deprived  of  sensation  is  too 
badly  diseased  to  bear  the  weight  and  resist  the  insult  result- 
ant upon  the  part  being  called  to  do  its  normal  or  even  an 
extra  amount  of  work,  it  must  ultimately  give  way,  the 
bones  become  fractured,  the  tendons  separate  from  the  bone, 
the  intra-ungular  tissues  lose  their  integrity  and  the  hoofs 
become  detached  (exungulation)  or  other  degenerative 
changes  take  place  as  a  result  of  causing  a  part  to  do  a 
work  for  which  its  condition  unfits  it. 

The  second  great  danger  occurs  from  wounds  or  other 
traumatisms  to  the  tissues  distal  to  the  operation  when  the 


NEUROTOMY. 


163 


unnerved  parts  are  not  rested  as  they  would  be  in  natural 
conditions  when  injured,  and  as  a  result  reparative  changes 
are  prevented  and  supplanted  by  retrograde  processes  with 
ultimate  death  of  the  part  and  of  the  animal. 

In  other  words  sensory  neurotomy  robs  an  organ  or  tissue 
of  the  enormously  conservative  force  of  pain.  Pain  causes 
the  animal  to  rest  the  affected  part,  protects  the  painful 
tissues  against  disintegrating  and  destructive  insults  and 
favors  restorative  processes  ;  robbed  of  this  protective  in- 
fluence of  pain  by  the  severance  of  the  sensory  nerves,  the 
diseased  tissues  are  without  their  natural  protection. 

Nerves  are  generally  accompanied  by  satellite  arteries  and 
veins  which  are  always  liable  to  be  wounded  during  the 
neurotomj^  and  are  more  embarassing  because  of  the  hemor- 
rhage clouding  the  operation  field  and  inviting  error  than 
dangerous  because  of  the  loss  of  the  blood  itself.  It  is 
essential  to  a  good  operation  that  the  hemorrhage  be  kept 
under  control  throughout  so  that  each  tissue  will  stand  out 
in  relief  and  the  nerve  reveal  its  identity  in  addition  to  its 
location,  size  and  relations,  by  its  intensely  white,  nacrous, 
striated  character.  The  test  of  compressing  the  nerve  in 
order  to  identify  it  by  the  resultant  pain  is  unsurgical  and 
unnecessarily  cruel. 

Sepsis  holds  an  important  place  in  considering  the  dangers 
of  neurotomy  because  the  infection  of  a  sensitive  nerve 
causes  very  great  pain  and  if  considerable,  tends  to  cause  a 
false  neuroma  or  fibroma  in  the  connective  tissue  of  the 
nerve  trunk,  calling  for  a  second  operation  in  order  to  re- 
move the  tumor,  and  resultant  lameness. 

Neurotomies  should  consequently  be  performed  only  in 
properly  selected  cases,  the  smallest  possible  trunk  that  will 
sufficiently  relieve  the  pain  should  be  selected  for  the  opera- 
tion, it  should  be  performed  with  due  regard  for  suffering 
and  for  asepsis,  should  be  performed  quickly  and  neatly,  the 
incisions  being  free,  laying  the  nerve  trunk  bare  without 
tearing  up  the  tissues  and  clouding  them  and  at  every  point 
aim  at  celerity,  accuracy  and  neatness. 


Plate  XXVI. 

Digital  Neurotomy. 

V,   Digital  vein  ;    A,  digital  artery  ;  N,  principal  digital 
nerve  ;  L,  ligament. 


DIGITAL  NEUROTOMY.  1 67 

36.     DIGITAL  NEUROTOMY. 
Plate  XXVI. 

Objects.  The  relief  of  navicular  lameness  in  cases  where 
plantar  neurotomy  is  not  deemed  necessary  or  advisable. 

Instruments.  Razor,  scissors,  scalpel,  probe  pointed 
bistoury,  tenacula,  aneurism  needles,  bandages. 

Technic.  Digital  neurotomy  may  generally  be  perform- 
ed on  the  standing  animal,  the  operative  area  having  first 
been  anaesthetized  by  means  of  cocaine  or  otherwise,  a 
twitch  applied  to  the  upper  lip  and  the  affected  foot  held  up 
by  an  assistant.  If  necessary  because  of  restlessness  of  the 
animal  or  inexperience  of  the  operator,  confine  on  the  oper- 
ating table  or  cast  the  animal  and  apply  the  extension  splint 
to  the  foot  to  be  operated  on  as  shown  in  Plate  XXIII,  ex- 
cept that  the  lower  binding  cords  rest  on  the  metacarpus 
instead  of  the  pastern. 

Extending  downwards  from  the  fetlock  joint  toward  the 
coronet,  between  the  posterior  border  of  the  first  phalanx 
and  the  anterior  border  of  the  flexor  tendons  there  is  a  slight 
furrow,  at  the  posterior  part  of  which,  close  to  the  external 
margin  of  the  tendon,  lies  the  median  or  principal  digital 
nerve  accompanied  in  front  by  the  digital  artery,  A,  anterior 
to  which  lies  the  digital  vein,  V.  Immediately  behind  the 
nerve  and  generally  lying  a  trifle  deeper,  is  quite  commonly 
found  a  second  venous  trunk  of  considerable  size.  Near  the 
middle  of  the  first  phalanx  the  nerve  is  crossed  externally 
in  an  oblique  direction  from  above  to  below  and  from  behind! 
to  before  by  a  white  ligamentous  band,  ly,  slightly  broader 
than  the  nerve  extending  from  the  base  of  the  ergot  of  the 
fetlock  to  the  retrossal  process  of  the  pedal  bone.  This  must 
not  be  mistaken  for  the  nerve,  N,  and  need  not  be  if  it  is  re- 
membered that  the  latter  is  accompanied  on  the  same  plane 
and  in  a  like  direction  by  the  satellite  artery,  A,  and  vein,  V, 
enclosed  with  it  in  a  fibrous  sheath.  At  the  uppermost  part 
of  the  first  phalanx  the  nerve  lies  in  front  of  this  ligament, 


168  DIGITAL  NEUROTOMY. 

a  short  distance  inferiorly  it  passes  beneath  it,  while  from 
the  middle  of  the  pastern  downwards  the  nerve  lies  behind 
the  ligament. 

The  operation  is  practicable  at  any  point  over  the  line  of 
the  nerve  from  the  top  to  the  bottom  of  the  shaved  area  in 
Plate  XXVI  or  from  the  superior  end  of  the  first  phalanx 
down  to  a  level  with  the  superior  border  of  the  lateral  carti- 
lage, but  preferably  at  about  the  point  shown  in  Plate  XXVI , 
near  the  superior  end  of  the  first  phalanx.  At  the  desired 
point  and  over  the  groove  betw^een  the  flexor  pedis  tendon 
and  the  phalanges  shave  and  disinfect  an  area  4  to  5  cm. 
square.  In  the  center  of  this  area  at  the  anterior  border  of 
the  flexor  tendon,  with  the  scalpel  held  perpendicular  to 
the  skin,  make  an  incision  from  above  downwards  a  distance 
■of  from  2  to  3  cm.  cutting  cleanly  through  the  skin  and 
subcutaneous  fascia  down  upon  the  nerve.  The  incision  is 
favored  by  tensing  the  skin  between  the  thumb  and  index 
finger  of  the  left  hand,  but  care  should  be  taken  not  to  dis- 
place it  backwards  or  forwards.  Dilate  the  wound  by 
pressure  upon  the  skin  with  the  thumb  and  index  finger  or 
otherwise  and  carefully  incise  longitudinally  the  fibrous 
sheath  enveloping  the  nerve  and  artery.  Pass  an  aneurism 
needle  beneath  the  nerve,  and  forcing  it  upward  and  down- 
ward, separate  thereby  the  nerve  from  the  surrounding 
tissues.  Insert  a  probe  pointed  bistoury,  or  scissors  beneath 
the  nerve,  and  divide  it  at  the  upper  angle  of  the  wound 
and  excise  a  section  3  cm.  long.  Disinfect  and  bandage 
with  or  without  suturing  the  wounds.  Leave  the  bandage 
in  place  6  to  8  days. 


PLANTAR  NEUROTOMY.  169 

37.     PLANTAR  NEUROTOMY. 
Plate  XXVII. 

Object.  The  relief  of  navicular,  or  ringbone  lameness 
or  other  painful,  non-suppurating  disease  of  any  parts  below 
the  fetlock  joint. 

Instruments.  Razor,  scissors,  convex  scalpel,  compres- 
sion arterj'  forceps,  tenacula,  aneurism  needles,  suture  ma- 
terial, elastic  ligature. 

Technic.  It  is  well  to  shave  the  site  of  operation  and 
thoroughly  disinfect  the  region  of  the  metacarpus  and  fet- 
lock with  soap,  brush,  and  sublimate  or  creolin  solution  and 
50%  alcohol,  and  apply  a  bandage  saturated  with  sublimate  or 
creolin  solution  to  the  fetlock  joint  24  hrs.  before  the 
operation  in  order  to  secure  thorough  disinfection. 

Confine  the  animal  and  fix  the  limb  as  in  the  preceding 
operation.  After  the  removal  of  the  disinfecting  bandage, 
and  producing  local  anaesthesia  pass  the  fingers  from 
before  to  behind  with  light  pressure  over  the  region  just 
above  the  fetlock  joint,  where  there  is  felt  immediately  in 
front  of  the  flexor  pedis  tendon  a  channel- like  depression 
extending  from  above  the  fetlock  dow^nward  over  it.  Just 
at  the  anterior  margin  of  the  flexor  pedis  tendon  and  at 
the  posterior  part  of  the  groove  lies  the  threadlike  cord 
of  the  nerve,  «,  3  mm.  thick,  which  glides  away  from 
underneath  the  fingers  with  a  distinct  recoil.  The  site  of 
operation  lies  immediately  above  the  fetlock  in  the  posterior 
third  of  the  metacarpus  or  one  may  operate  at  any  point 
higher  up  as  far  as  beyond  the  middle  of  the  metacarpus  or 
metatarsus  so  long  as  care  is  taken  to  include  the  anasto- 
mosing branch  given  off  by  the  median  plantar  nerve  at 
about  the  middle  of  the  metacarpus  and  bending  obliquely 
around  behind  the  tendons  to  join  the  lateral  nerve  some- 
what lower  down.  At  this  point  stretch  the  skin  between 
the  thumb  and  index  finger  of  one  hand  and  make  an   in- 


Plate  XXVII. 

Plantar  Neurotomy. 

a,  lateral  digital  artery  ;  v,  lateral  digital  vein  ; 
n,  common  lateral  digital  nerve ;  d,  anterior 
branch  ;  o,  posterior  branch  ;  s,  superficial  flexor 
tendon  ;  p,  perforans  tendon  ;  z,  suspensory 
ligament  of  fetlock  ;  ;;/,  metacarpus. 


PLANTAR   NEUROTOMY. 


173 


cision  3  to  5  cm.  long,  the  lower  angle  of  which  is  usually 
just  above  the  fetlock  joint,  cutting  directly  through  the 
skin,  subcutem  and  connective  tissue  sheath  down  onto  the 
nerve,  laying  it  bare.  The  borders  of  the  cutaneous  wound 
are  held  apart  with  tenacula  and  by  palpation  with  the 
fingers  or  by  vision  it  is  determined  if  the  nerve  lies  in  the 
middle  of  the  wound.  If  necessary  continue  the  dissection 
with  the  scalpel  until  the  nerve  is  clearly  revealed  ;  it  is 
distinguished  by  its  faintly  yellowish  color,  its  fine  longi- 
tudinal striae  and  its  location  behind  the  metacarpal  artery. 
Immediately  above  the  fetlock  joint  the  median  metacar- 
pal or  metatarsal  nerve  divides  into  an  anterior  smaller,  d, 
and  posterior  larger  branch,  0.  This  division  should  be 
laid  bare  in  order  that  the  operator  may  not  erroneously 
cut  one  branch  only.  Immediately  above  this  point  of 
division  the  aneurism  needle  is  passed  under  the  nerve, 
pushed  well  through  and  forced  up  and  down,,  separating 
the  nerve  from  the  adjacent  tissues,  the  scissors  or  a  small 
probe-pointed  bistoury  is  passed  beneath  and  it  is  cut 
through  quickly  at  the  superior  angle  of  the  wound.  The 
distal  end  of  the  nerve  is  then  dissected  free  downward 
and  excised  at  the  lower  angle  of  the  wound  so  that  a  section 
3  to  5  cm.  long  is  removed.  The  cutaneous  wound  is  united 
by  a  continuous  suture  and  a  temporary  bandage  applied. 
If  the  horse  has  been  secured  by  casting,  the  extension 
splint,  if  it  has  been  used,  is  then  removed,  the  foot  replaced 
in  the  hobble  and  the  horse  turned  to  the  other  side.  The 
operation  on  the  opposite  metacarpal  nerve  is  carried  out 
in  the  same  way  after  which  a  sterile  bandage  is  applied  and 
allowed  to  remain  eight  days.     Healing  by  primary  union. 


174         NEUROTOMY  OF  THE  MEDIAN  NERVE. 

38.     NEUROTOMY  OF  THE  MEDIAN  NERVE. 
PlatB  XXVIII. 

Objects.  The  relief  of  lameness  due  to  disease  so  located 
in  the  anterior  limb  that  it  cannot  be  so  well  overcome  by 
plantar  neurotomy. 

Instruments.  Razor,  scissors,  convex  scalpel,  artery 
and  compression  forceps,  tenacula,  aneurism  needles,  suture 
material. 

Technic.  The  operation  is  performed  on  the  median 
surface  of  the  anterior  limb  immediately  below  the  humero- 
radial articulation  on  the  recumbent  horse  after  the  affected 
foot  has  been  fully  extended  on  the  operating  table  or  in  de- 
fault of  this  removed  from  the  hobbles  and  bound  upon  the 
extension  splint  as  shown  in  Plate  XXIII.      Anaesthetize. 

The  foot  is  drawn  out  firmly  from  the  shoulder,  incHned 
somewhat  forward.  The  operator  places  himself  between 
the  neck  and  the  forearm  of  the  patient  and,  after  the  median 
region  of  the  elbow  joint  has  been  washed  with  soap  and 
water,  searches  for  the  median  nerve  where  it  glides  over 
the  posterior  part  of  the  joint  to  disappear  behind  the  radius. 
Shave  the  skin  at  and  below  this  point,  disinfect  it  with 
sublimate  or  creolin  solution  and  50%  alcohol.  The  nerve, 
n,  lies  as  a  rule  somewhat  in  front  of  the  middle  of  the 
median  side  of  the  forearm  against  the  postero-internal 
margin  of  the  radius  and  can  be  felt,  about  5  to  6  mm.  in 
diameter,  lying  somewhat  deeply.  The  position  of  the 
nerve  varies  with  the  different  attitudes  of  the  forearm.  In 
fat  and  fleshy  horses  the  identification  of  the  nerve  is  more 
difficult.     It  may  be  felt  upon  the  standing  animal. 

With  the  nerve  lying  between  the  thumb  and  index  finger 
of  the  left  hand,  at  the  point  where  it  begins  to  disappear 
behind  the  radius  after  having  passed  over  the  humero-radial 
articulation,  stretch  the  superposed  skin  and  immediately 
upon  and  parallel  to  it  make  an  incision  5  cm.  long,  first 
through  the  skin,  then  through  the  aponeurotic  expansion 


NEUROTOMY  OF  THE  MEDIAN  NERVE. 


175 


of  the  sterno-aponeuroticus  muscle.  Check  any  hemorrhage 
from  the  skin,  subcutis,  or  muscle.  The  tenacula  are  in- 
serted cautiously  in  the  lips  of  the  wound,  and  these  being 
drawn  apart  the  white  anti-brachial  fascia  is  brought  into 
view  and  a  search  is  made  with  the  index  finger  to  determine 
the  exact  location  of  the  nerve,  the  fascia  is  divided  with 
the  scalpel  and  an  oval  piece  excised  with  the  scissors  im- 
mediately over  the  nerve.  If  much  fatty  tissue  is  found  be- 
neath the  fascia  it  may  be  dissected  away  carefully  with  the 
scalpel  or  cut  away  with  the  scissors.  There  now  comes  in- 
to view  a  delicate  reddish  colored  fascia-like  membrane,  the 
nerve  sheath,  behind  which  a  dark  cord,  the  brachial  vein, 
V,  is  visible,  the  latter  being  intimately  connected  with  the 
nerve  sheath.  The  vein  lies  mostly  behind  and  beneath  the 
nerve  and  may  project  out  from  beneath  the  border  of  the 
same.  The  operator  needs  be  careful  not  to  prick  this  vein  with 
the  tenacula,  as  the  hemorrhage  therefro?n  is  exceedi^igly  annoy- 
ing'during  the  operation.  Avoid  the  use  of  tenacula  after  pene- 
trating the  fascia  and  retract  the  tvound  lips  cautiously  with 
aneurisr7i  Jieedlcs  instead.  Still  further  forward  and  deeper 
may  be  felt  the  pulsating  brachial  artery.  Incise  the  nerve 
sheath  carefully  and  divide  it  upward  and  downward  with 
the  scalpel  or  scissors,  whereupon  the  yellowish  and  dis- 
tinctly fibrous  nerve  comes  into  plain  view.  Pass  an 
aneurism  needle  beneath  the  nerve  pushing  it  so  far  through 
that  the  distal  end  is  readily  grasped  and  drawing  it  up  and 
down  with  the  two  hands,  separate  the  nerve  from  the 
adjacent  tissues  throughout  the  length  of  the  wound. 
Be  careful  to  not  cut  the  nerve  too  high  ajid  erroneously 
include  the  motor  nerve  of  the  flexor  of  the  metacarpus  and 
the  flexors  of  the  foot,  which  is  generally  giveyi  off  posteri- 
■orly  just  below  the  htcmero  radial  articulation.  Lift  the  nerve 
up  and  cut  it  through  at  the  superior  angle  of  the  wound 
by  a  sudden  clip  with  the  scissors  or  with  the  probe  pointed 
bistoury.  Lay  the  peripheral  end  of  the  nerve  bare  to  the 
lower  angle  of  the  wound,  and  excise  at  least  3  cm.  of  it. 


Plate  XXVIII. 

Median  Neurectomy. 

Median  surface  of  the  right  humero  radial 
articulation.  a,  brachial  artery  ;  n,  median 
nerve  ;  v,  brachial  vein  ;  f,  antibrachial  fascia  ; 
p,  Fterno-aponeuroticus  muscle. 


NEUROTOMY  OF   THE  ULNAR  NERVE. 


179 


Tamponade  the  wound  with  dry  iodoform  gauze  and  ap- 
proximate the  skin  with  a  continuous  suture.  The  tampon 
and  sutures  remain  1  to  2  days. 

Since  sensation  of  the  lower  part  of  the  limb  is  partly 
maintained  by  the  deep  branch  of  the  ulnar  nerve  which  at 
the  lower  part  of  the  carpus,  covered  by  the  tendon  of  the 
oblique  flexor  becomes  the  lateral  plantar  nerve,  neurotomy 
of  the  median  nerve  does  not  always  completely  effect  the 
desired  end.  In  order  to  produce  complete  anaesthesia  of 
the  foot,  therefore,  it  is  necessary  to  perform  ulnar 
neurotomy. 


39.     NEUROTOMY  OF  THE  ULNAR  NERVE. 
Plates  XXIX-XXX. 

Object.  An  adjunct  operation  of  the  preceding  by 
which  the  enervation  of  the  carpus  and  foot  is  completed. 

Instruments.     Same  as  in  the  preceding. 

Technic.  Above  and  behind  the  carpus  there  may  be 
felt  a  groove  between  its  external  and  middle  flexors,  EF 
and  OF,  Plate  XXX.  At  this  point  10  cm.  above  the 
pisiform  bone  the  skin  is  shaved  and  disinfected  and  an  in- 
cision 6  cm.  long  made  through  the  skin  and  antibrachial 
fascia.  This  incision  extends  just  outside  the  median  line 
of  the  posterior  surface  of  the  radius  in  such  a  way  that  the 
superior  angle  of  the  wound  is  about  i  cm.  farther  out- 
ward than  the  lower.  Beneath  the  fascia  between  the 
aforesaid  muscles  is  seen  the  ulnar  nerve,  Plate  XXIX,  n 
Plate  XXX,  NU,  on  the  median  or  inner  side  of  it  the 
collateral  ulnar  vein,  Plate  XXIX  v,  and  between  the  two 
and  somewhat  deeper  the  collateral  ulnar  artery,  a.  The 
nerve,  about  3  mm.  in  diameter  is  picked  up  with  the 
aneurism  needle,  severed  at  the  upper  and  lower  angles  of 
the  wound,  the  lips  of  the  wound  united  by  a  continuous 
suture  and  a  bandage  applied.     Healing  by  first  intention. 


Plate  XXIX. 


Ulnar  Neurotomy. 


Right  forearm  seen  from  behind,  e,  external 
flexor  of  the  carpus;/,  oblique  (middle)  flexor 
of  the  carpus ;  a,  collateral  ulnar  artery  ;  d, 
antibrachial  fascia  ;  n,  ulnar  nerve. 


Plate  XXX. 

Ulnar  Neurotomy. 

Cross  section  through  the  forearm,  about 
lo  cm.  above  the  pisiform  bone,  viewed  from 
below.  EF,  external  flexor  of  the  carpus ; 
OF,  oblique  flexor  of  the  carpus ;  NU,  ulnar 
nerve  ;  NM,  median  nerve.  Lying  on  its  median 
side  is  the  ulnar  artery,  the  satellite  vein  of 
which  is  not  shown. 


i85 


SCIATIC  NEUROTOMY. 

40.    SCIATIC  NEUROTOMY. 
Plates  XXXl-XXXll. 

Objects.  The  destruction  of  sensation  in  the  tarsus  and 
parts  beyond  for  the  relief  of  otherwise  incurable  spavin 
lameness,  diseases  of  the  tendons,  etc. 

Instruments.     Same  as  in  the  preceding. 

Technic.  Expert  surgeons  may  operate  on  the  standing 
animal  under  local  anaesthesia.  Place  the  animal  on  the 
operating  table  on  the  diseased  side,  extend  the  affected 
limb  and  draw  the  upper  leg  forward  or  backward  and 
secure  it  out  of  the  way.  Produce  complete  general  or  local 
anaesthesia.  The  posterior  tibial  or  sciatic  nerve,  n,  Plate 
XXXI  and  NS,  Plate  XXXII,  is  then  sought  by  grasping 
the  leg  with  the  left  hand  from  behind  in  such  a  manner 
that  the  thumb  rests  above  and  the  fingertips  below  it. 
Reaching  forward  with  the  fingers  to  the  deep  flexor  of  the 
foot  grasp  the  leg  with  moderate  firmness  and  draw  the 
hand  slowly  backward.  Immediately  behind  the  perforans 
muscle  and  between  this  and  the  tendo- Achilles  the  nerve, 
nearly  i  cm.  in  diameter,  glides  away  forward  from  be- 
tween the  fingers  with  a  distinct  recoil.  If  the  nerve  can 
not  be  recognized  in  this  manner  the  hock  should  be  more 
strongly  extended,  by  which  means  the  nerve  may  be  caused 
to  recede  from  the  perforans  muscle,  so  that  it  can  more 
readily  be  felt  near  the  middle  of  the  groove  extending  be- 
tween it  and  the  tendo- Achilles. 

At  this  point  on  the  median  side  of  the  leg  the  skin  is 
shaved,  disinfected  and  an  incision  made  through  it  5  cm. 
long,  parallel  to  the  tendo-Achilles.  The  white  rigidly- 
stretched  crural  fascia  is  now  divided  in  the  same  direction 
after  which  it  should  be  determined  by  palpation  that  the 
nerve  lies  in  the  middle  of  the  wound.  Exci.se  with  the 
scissors  an  elliptic  or  oval  piece  of  the  fascia  or  hold  it 
apart  along  with  the  lips  of  the  cutaneous  wound  by  means 


Plate  XXXI. 

Sciatic  Neurotomy. 

Right  hind  leg  viewed  from  the  median  side, 
/,  crural  fascia;  «,  sciatic  (tibial)  nerve;  v, 
plantar  vein. 


Plate  XXXII. 

Tibio-Peroneal  Neurotomy. 

Cross  section  through  the  tibia  at  about  lo  cm.  above  the  tibio- 
astragaloid  articulation.  SA,  recurrent  tibial  arter}- ;  NS,  sciatic 
nerve  ;  NMC,  musculo-cutaneous  branch  of  anterior  tibial  nerve  ;  NP, 
deep  or  sensory  branch  of  anterior  tibial  or  peroneal  nerve  ;  EP,  ex- 
tensor pedis  muscle  ;  MP,  peroneus  muscle  ;  FM,  flexor  metatarsi 
muscle. 


f« 


'^ 


ANTERIOR  TIBIAL  NEUROTOMY.  191 

of  the  tenacula.  In  poor  horses  the  contour  of  the  nerve, 
covered  only  by  loose  connective  tissue,  stands  out  promi- 
nently, in  fat  horses  it  is  surrounded  by  a  large  amount  of 
adipose  tissue.  Cut  through  this  fat  and  connective  tissue 
and  expose  the  tibial  nerve,  n,  Plate  XXXI  and  NS,  Plate 
XXXII,  to  view  ;  immediately  before  it  lies  the  plantar 
vein  and  on  the  lateral  side  is  situated  the  recurrent  tibial 
-artery,  SA,  Plate  XXXII.  The  cross  section  in  Plate 
XXXII  is  located  somewhat  below  the  point  for  operation 
and  the  vein  has  crossed  obliquely  over  the  nerve  so  that 
it  appears  behind  instead  of  in  fro7it  of  it,  as  is  the  case 
generally  at  the  point  where  the  operation  is  performed. 
-Separate  the  vessels  completely  from  the  nerve  with  the 
handle  of  the  scalpel,  pass  an  aneurism  needle  from  before 
"backward  beneath  it  through  to  the  handle  and  grasping 
both  ends  force  the  instrument  upwards  and  downwards  in 
•order  to  separate  the  nerve  trunk  from  the  adjacent  tissues. 
Cut  the  nerve  off  at  the  upper  and  lower  angles  of  the 
wound  removing  a  section  at  least  5  cm.  long.  Suture  the 
cutaneous  wound  and  apply  a  bandage  allowing  it  to  remain 
■eight  days.     Healing  should  occur  by  first  intention. 


41.     ANTERIOR  TIBIAL  NEUROTOMY. 

Neurotomy  of  the  Deep  Branch  of  the  Peroneal  Nerve. 

Plates  XXXII-XXXI/I. 

Object.  An  adjunct  operation  to  the  preceding  since  this 
-nerve  supplies  sensation  to  the  tarsus  in  common  with  the 
•sciatic.  The  two  constitute  what  is  known  as  Bossi's  double 
neurotomy  for  spavin. 

Instruments.     Same  as  in  the  preceding. 

Technic.  Confine  as  in  the  preceding  but  with  the 
affected   leg   uppermost.     Locate   the   furrow  dividing  the 


Plate  XXXIII. 

Anterior  Tibial  Neurotomy. 

EP,  extensor  pedis  muscle ;  P,  peroneus 
muscle  ;  NP,  deep  branch  of  the  peroneal  or 
anterior    tibial    nerve ;     FM,    flexor    metatarsi 

muscle. 


13 


ANTERIOR  TIBIAL  NEUROTOMY 


195 


extensor  pedis  longus,  EP,  Plates  XXXII-XXXIII,  aud 
the  peronens  muscles,  P,  Plate  XXXIII,  MP,  Plate  XXXII, 
and  shave  and  disinfect  an  area  6  cm.  long  by  3  cm.  wide 
directly  over  this  depression  and  extending  upward  from  a 
point  6  to  7  cm.  above  the  tibio-astragaloid  articulation. 

At  a  point  8  to  10  cm.  above  the  flexure  of  the  hock  make 
an  incision  through  the  skin  and  subcutis  5  or  6  cm.  long 
over  the  line  of  division  between  the  two  extensors  of  the 
foot.  Superficially  the  operator  passes  near  by  the  musculo- 
cutaneous division  of  the  anterior  tibial  nerve,  NMC,  Plate 

XXXII,  which  must  not  be  mistaken  for  the  deep  branch. 
The  peroneus  muscle,   MP,   Plate  XXXII,  and  P,  Plate 

XXXIII,  is  separated  from  the  extensor  pedis  longus,  EP, 
Plates  XXXII  and  XXXIII,  by  a  strong  aponeurotic  sheath 
continuous  with  the  tibial  aponeurosis.  Penetrate  the  tibial 
aponeurosis  anterior  to  the  aponeurotic  partition  directly 
against  the  extensor  pedis,  EP,  and  passing  along  the 
posterior  border  of  this  muscle  to  a  depth  of  2  to  4  cm., 
there  appears  the  thin  margin  of  the  flexor  metatarsi 
magnus,  FM,  Plates  XXXII  and  XXXIII,  which  lies  im- 
mediately against  the  extensor  pedis  without  a  visible  con- 
nective tissue  partition  but  revealing  itself  by  a  markedly 
lighter  shade  of  color  and  its  ready  separation  from  the  ex- 
tensor with  the  scalpel.  The  deep  branch  of  the  peroneal 
nerve,  NP,  Plates  XXXII  and  XXXIII,  lies  loosely  im- 
bedded on  the  anterior  side  of  the  margin  of  the  flexor  meta- 
tarsi facing  the  extensor  pedis,  at  times  visible  at  the  margin, 
at  others  placed  more  deeply  reaching  in  some  cases  a  distance 
from  the  margin  of  4  or  5  mm.  Within  this  range  is  seen 
the  slender  nerve  trunk  almost  devoid  of  surrounding  con- 
nective tissue  and  measuring  about  2  ram.  in  diameter. 
Pass  the  aneurism  needle  beneath  it  and  remove  a  piece  3 
to  4  cm.  long.  Close  the  cutaneous  wound  with  interrupted 
sutures  and  dress  antisptically  without  a  bandage. 


ig6      RESECTION  OF  THE  LATERAL  CARTILAGE. 

42.     RESECTION  OF  THE  LATERAL  CARTILAGE. 

The  Bayer  Quittor  Operation. 

Plate  XXXIV. 

Object.  The  cure  of  quittor  or  necrosis  of  the  lateral 
cartilage. 

Instruments.  Elastic  ligature,  drawing  knife,  scissors, 
razor,  hoof  ra.sp.  hoof  plane,  craniotomy  or  other  heavy  for- 
ceps for  the  removal  of  the  horn,  artery  forceps,  elevator  or 
long  bone  chisel,  right  and  left  sage  knives,  curette,  needle 
holder,  thread,  needles,  iodoform  ether,  iodoform  gauze, 
tampons,  absorbent  cotton,  bandages. 

Technic.  For  a  few  hours  before  the  operation  place 
the  affected  foot  in  a  bath  of  creolin  or  other  antiseptic 
solution  after  having  first  rasped  the  diseased  quarter /z^^/*/}/ 
and  make  a  semicircular  groove  in  the  horn  of  the  lateral 
wall  and  quarter  down  to  the  horny  lamina,  as  shown  at  s 
in  Fig.  I,  Plate  XXXIV.  It  is  essential  to  not  materially 
thin  the  horn  on  the  quarter  with  the  rasp  since  by  weaken- 
ing it,  it  yields  and  breaks  and  cannot  be  properly  detached 
from  the  senitive  laminae. 

The  operation  is  peformed  upon  the  recumbent,  anaes- 
thetized animal,  in  such  a  position  that  the  diseased  cartilage 
of  the  affected  foot  lies  upward.  The  operating  table  consti- 
tutes incomparably  the  best  means  of  confinement  in  every 
respect.  After  the  application  of  the  elastic  ligature  in  the 
metacarpal  or  metatarsal  region  the  groove  in  the  horn  is 
deepened  with  the  drawing  knife  down  to  the  sensitive 
laminae  without  injuring  them.  The  groove  must  be  so 
located  that  it  extends  beyond  the  anterior  and  posterior 
borders  of  the  lateral  cartilage,  and  downwards  to  within  i 
or  2  cm.  of  the  margin  of  the  os  pedis  and  approximately 
perpendicular  to  the  surface  of  the  horn  wall  so  that  it  will 
form  a  secure  support  for  the  dressing  to  be  later  applied. 
The  hair  on  the  coronary  band  is  clipped  or  shaved  and  the 


RESECTION  OF  THE  LATERAL  CARTILAGE. 


197 


entire  foot  up  to  the  fetlock  joint  thoroughly  cleansed  with 
brush,  soap,  creolin  or  sublimate  solution  and  50  per  cent, 
alcohol.  The  fetlock  and  pastern  are  carefully  wrapped  in 
a  towel  saturated  with  sublimate  solution  or  other  disin- 
fectant. The  hoof  should  be  similarly  wrapped  except  the 
operative  area  and  every  precaution  taken  against  the 
transfer  of  infecting  material  from  neighboring  parts  into 
the  wound.  The  elevator  or  long  bone  chisel  is  then  inserted 
beneath  the  lowest  part  of  the  semi-circular  piece  of  horn 
which  has  been  isolated,  the  horn  is  elevated  from  the 
sensitive  structures  somewhat,  grasped  with  the  heavy  for- 
ceps and  carefully  loosened  from  the  sensitive  parts  by 
drawing  upward  parallel  to  the  laminae  until  the  coronary 
band  is  reached  and  the  traction  is  then  directed  backwards 
toward  the  heel,  separating  the  wall  from  the  coronary 
papillae  and  keraphyllous  tissue.  Care  is  to  be  taken  here 
to  avoid  lacerating  the  underlying  tissues,  especially  when 
the  traction  is  first  directed  backwards.  If  the  soft  tissues 
threaten  to  tear  this  should  be  arrested  by  the  timely  use  of 
the  scalpel  or  sage  knife  as  conditions  may  suggest. 

After  the  coronary  band  has  been  smoothed  with  the 
scissors,  make  two  perpendicular  incisions  through  the  skin 
and  coronary  band,  one  behind  the  anterior  and  the  other  in 
front  of  the  posterior  border  of  the  groove  in  the  horn  and 
connect  the  two  by  means  of  a  semi-circular  incision  in  the 
sensitive  laminae.  This  U-shaped  incision  should  be  so 
made  that  between  it  and  the  horny  wall  there  is  left  an 
area  of  sensitive  laminae  i  to  2  cm.  wide,  in  order  that  there 
may  be  sufficient  room  in  the  soft  tissues  for  the  application 
of  the  sutures,  as  shown  in  Fig.  2.  The  lines  of  incision 
through  the  coronary  band  should  be  so  located  as  to  in- 
clude between  them  the  entire  lateral  cartilage. 

The  isolated  flap  is  now  dissected  closely  against  the  os 
pedis  and  its  ala  and  from  the  lateral  surface  of  the  carti- 
lage, the  operator  lifting  the  flap  with  forceps  or  tenaculum. 


Plate 


Fig.  1. 

Resection  of  the  Lateral  Cartilages  of  the  os  Pedis. 

Horny  wall  removed,  sensitive  laminae  and  cutaneous  flap  held 
upwards.  Posterior  half  of  the  cartilage  excised.  /,  sensitive  lam- 
inae ;  zv,  coronary  band ;  k,  anterior  half  of  cartilage ;  A,  cavity 
caused  by  the  removal  of  the  posterior  half  of  the  cartilage  ;  n,  necrotic 
cartilage  ;  />,  parachondral  surface  of  the  skin  and  sensitive  laminae  ; 
s,  perpendicular,  crescent-shaped  incision  in  the  horny  wall ;  £\  fistula. 


XXXIV. 


Fig.  2. 

Resection  of  the  Lateral  Cartilages  of  the  os  Pedis. 

Completed  operation  showing  the  sutures   in  place  and  the^  parts 
ready  for  the  application  of  dressings. 


200      RESECTION  OF  THE  LATERAL  CARTILAGE. 

Above  the  cartilage  toward  the  fetlock  the  operator  must 
keep  the  fingers  of  one  hand  against  the  external  skin  in 
order  to  avoid  cutting  through  it  or  thinning  it  too  much 
at  this  point.  The  flap  is  held  turned  upwards  by  an  assist- 
ant or  a  strong  suture  is  passed  through  it  and  turning  it 
upwards  the  suture  ends  are  carried  around  the  pastern  and 
tied. 

As  a  rule  there  is  now  seen  a  prominent,  greenish  colored 
necrotic  piece  of  cartilage  surrounded  by  brownish  red 
masses  of  granulations.  By  means  of  an  incision  through 
the  cartilage  parallel  to  the  long  axis  of  the  foot,  divide  it 
into  anterior  and  posterior  halves  and  extirpate  the  latter 
first  by  dissecting  it  out  on  the  inner  side  from  the  para- 
chondral  tissue  with  the  sage  knife.  Begin  the  excision 
of  the  cartilage  by  engaging  the  supero-anterior  angle  of 
the  posterior  half  with  the  tenaculum  and  exerting  moderate 
traction  dissect  it  away  from  the  underlying  tissues  first 
along  the  line  of  the  dividing  incision  down  to  the  base  and 
then  cut  backward  toward  the  heel  cutting  the  cartilage 
away  from  its  continuous  bone.  The  point  of  the  knife  must 
be  constantly  directed  against  the  ca?'tilage. 

Since  the  inner  surface  of  the  anterior  half  of  the  cartilage 
lies  immediately  against  the  capsular  ligament  of  the  corono- 
pedal  articulation  the  latter  should  be  sharply  extended  by 
an  assistant  seizing  the  toe  and  forcing  it  forward.  By 
this  means  the  capsular  ligament  is  drawn  away  from  the 
cartilage  during  its  extirpation. 

The  anterior  half  of  the  cartilage,  k,  is  then  removed  in 
the  same  way,  except  with  the  greatest  possible  care  to 
avoid  puncturing  the  corono-pedal  articulation.  The  chief 
precaution  is  to  dissect  only  with  the  point  of  the  sage  knife, 
using  at  all  times  that  knife,  right  or  left,  which  will  result 
in  the  concave  surface  being  presented  toward  the  cartilage  ; 
then  by  carefully  keeping  the  line  of  excision  immediately 
.against  the   cartilage,    material  danger  of  penetrating  the 


RESECTION  OF  THE  LATERAL  CARTILAGE.      201 

joint  is  avoided.  Remnants  of  cartilage  at  its  juncture 
with  the  retrossal  process  of  the  os  pedis,  and  granulations 
are  to  be  removed  with  the  curette.  Cut  away  with  the 
scissors  and  knife  any  remnants  of  cartilage  adherent  to 
the  flap,  p,  thin  if  necessary  the  entire  flap  and  excise  the 
fistulous  openings,  g.  After  thorough  disinfection  of  the 
entire  field  of  operation  sprinkle  it  over  thickly  with 
powdered  iodoform  and  return  the  flap  to  its  former  position 
and  retain  it  there  by  a  sufficient  number  of  interrupted 
sutures  as  shown  in  Fig.  2.  The  first  sutures  to  be  applied 
should  be  at  the  border  line  between  the  skin  and  coronary 
band  so  as  to  insure  accurate  apposition  at  this  point. 
Sprinkle  the  wound  surface  with  iodoform  and  cover  the 
parts  over  with  iodoform  gauze  and  tampons  which  rest 
firmly  upon  the  perpendicular  wall  of  horn.  Finally  invest 
the  hoof  and  pastern  up  to  the  fetlock  joint  with  an  abund- 
ance of  oakum  saturated  with  i-iooo  sublimate  solution 
and  lay  a  heavy  tar  bandage  over  it,  the  turns  of  which 
must  completely  invest  it  at  every  point  and  render  the 
dressing  impermeable  to  moisture.  Remove  the  elastic  liga- 
ture. If  the  animal  is  free  from  fever,  feels  and  eats  well, 
the  bandege  is  left  in  position  from  12  to  14  days.  Healing 
by  first  intention. 

The  two  chief  dangers  in  the  operation  are  the  opening 
of  the  corona-pedal  articulation  and  the  persistence  of  a 
scar  in  the  coronary  band  resulting  in  a  quarter  crack. 

If  the  operation  has  been  kept  thoroughly  antiseptic,  the 
opening  of  the  articulation  is  not  necessarily  serious. 

The  question  of  preventing  a  weakening  scar  at  the 
coronary  incision  is  one  of  strict  antisepsis  and  accurate 
suturing.  The  operation  frequently  fails  under  indifferent 
technic.     It  is  an  operation  for  the  careful  surgeon  only. 


202      RESECTION  OF  THE  FLEXOR  PEDIS  TENDON. 

43.    RESECTION  OF  THE  FLEXOR  PEDIS  TENDON. 

Fig.  15. 

Object.  The  removal  of  necrotic  tissues  and  disinfection 
in  cases  of  infected  wounds,  chiefly  of  nail  wounds  of  the 
navicular  bursa. 

Instruments.  Elastic  ligature,  drawing  knife,  sage 
knives,  scissors,  tenaculum  forceps,  curette,  scalpels, 
tenaculse,  bandage  material. 

Technic.  Before  the  operation  thin  the  horn  of  the  sole, 
frog  and  bars  until  the  soft  parts  can  be  seen  through  them 
and  apply  an  antiseptic  bandage  saturated  in  creolin  solution 
for  24  hours  if  time  will  warrant.  Secure  the  patient  on  the 
operating  table  or  by  casting  in  lateral  recumbency  with  the 
affected  foot  extended.  Anaesthetize.  Cleanse  and  disinfect 
the  entire  foot  with  soap,  brush,  creolin  or  sublimate  solution 
and  50%  alcohol  and  apply  the  elastic  tourniquet  in  the 
metacarpal  or  metatarsal  region.  Apply  towels  saturated 
with  antiseptics  as  in  preceding  operation.  Make  a  trans- 
verse incision  through  the  base  of  the  frog  2  to  3  cm.  from 
the  balls  through  the  horny  and  sensitive  portions  and  the 
fatty  cushion  down  to  the  flexor  pedis  tendon.  Follow  this 
by  two  converging  incisions  extending  forward  and  inward 
in  an  oblique  direction  corresponding  to  the^'semi-lunar  crest 
of  the  OS  pedis,  the  line  of  incision  being  in  the  bars  about 
^2  cm.  outward  from  the  lateral  groove  of  the  frog  and 
uniting  at  its  apex.  This  triangular  piece  of  frog  which 
has  been  isolated  by  the  incision  is  now  grasped  with  the 
tenaculum  and  dissected  away.  The  remnants  of  the  fatty 
frog  should  be  removed  with  the  sage  knife  or  scalpel  by 
means  of  a  horizontal  incision,  and  there  is  then  revealed 
the  flexor  pedis  tendon  which  may  be  greenish  or  yellowish 
colored  and  necrotic,  or  may  be  covered  with  reddish  colored 
granulations. 


RESECTION  OF  THE  FLEXOR  PEDIS  TENDON. 


203 


Should  there  be  present  also  suppurative  pododermatitis 
the  bars  on  the  affected  side  must  be  excised  along  with 
the  other  portions. 

The  position  and  extent  of  the  navicular  bone  can  be 
determined  by  palpating  the  flexor  tendon.  A  transverse 
incision  is  then  made  over  the  middle  of  the  navicular  bone 


Resection  of  the  Flexor  Pedis  Tendon. 

fl 
Solar  surface  of  the  foot,     r,  Semi-lunar  crest  of  os  pedis ; 
u,  OS  pedis  ;  r,  navicular-pedal  ligament ;  s,  navicular  bone ; 
d,  flexor  pedis  tendon  ;  e,  sensitive  laminae  of  the  bars  ;  si, 
fatty  frog  ;  /,  sensitive  frog  ;  //,  horny  frog. 

through  the  flexor  pedis  tendon  into  the  navicular  bursa, 
the  distal  end  of  the  tendon  grasped  with  the  tenaculum 
forceps  and  lifted  up  from  the  navicular  bone  with  the  aid  of 
two  lateral  curved  incisions.  Between  the  inferior  or  anterior 
border  of  the  navicular  bone  and  the  semi-lunar  crest  of  the 
OS  pedis  stretches  the  capsular  ligament  of  the  inferior 
articulation  reinforced  by  dense  fibrous  bands.     The  flexor 


204 


AMPITATION  OF  THE  CLAWS  OF  RUMINANTS. 


pedis  tendon  is  united  to  this  b}-  a  few  bundles  of  fibres. 
Dissect  the  tendon  carefully  away  from  the  capsular  liga- 
ment, avoiding  opening  the  articulation,  and  then  cut  it 
away  from  the  semi-lunar  crest  of  the  os  pedis.  If  necrotic 
or  discolored  pieces  of  the  fatty  cushion  or  the  tendon  still 
remain,  remove  these  with  scissors,  scalpel  or  curette. 
Curette  the  roughened  cartilage  of  the  navicular  bone  and 
remove  any  necrotic  or  inflamed,  softened  portions  of  the 
bone.  In  extensive  necrosis  of  the  suspensory  ligaments 
of  the  heel  and  of  the  ligaments  extending  from  the 
fetlock  joint  to  the  lateral  cartilages,  the  necrotic  portions 
as  well  as  the  neighboring  fatty  cushion  with  its  numer- 
ous elastic  fibres,  must  be  resected.  In  case  of  purulent 
areas  extending  along  the  tendon  and  opening  above  in 
the  heel,  draw  through  the  tract  a  large  strip  of  gauze 
thoroughly  saturated  with  tincture  of  iodine  and  allow  it  to 
remain.  If  the  suppurating  area  extends  well  up  into  the 
heel  without  an  opening,  incise  from  above  and  handle  as 
preceding.  Disinfect  the  operation  wound,  irrigate  with 
iodoform  ether  and  tamponade  it  with  dry  iodoform  gauze. 
Over  this  apply  a  firm  pad  of  oakum  saturated  with  i-iooo 
sublimate,  enclose  the  entire  hoof  up  to  the  fetlock  in  oakum 
and  apply  over  this  a  bandage.  Over  this  apply  a  tar 
bandage  and  remove  the  elastic  ligature.  In  the  absence  of 
fever  the  bandage  remains  in  position  for  8  to  12  days. 


44.    AMPUTATION  OF  THE  CLAWS  OF  RUMINANTS. 
Plate  XXXV. 

Uses.  The  cure  of  "foul  in  the  foot"  or  panaritium 
when  complicated  with  suppurative  arthritis  or  osteitis. 

Instruments.  Half  round  rasp,  .sage  knives,  scissors, 
convex  scalpel,  artery  forceps,  drawing  knife,  elastic  liga- 
ture, dressing  materials. 


AMPUTATION  OF  THE  CLAWS  OF  RUMINANTS. 


205 


Technic.  Cast  the  animal  and  secure  the  foot  to  be 
operated  upon  in  an  extended  position,  apply  the  elastic 
ligature  and  after  disinfecting  the  claws  rasp  away  the  horn 
on  the  lateral  side  of  the  diseased  claw,  especially  at  the  pos- 
terior part  of  it,  until  the  horny  wall  becomes  so  thin  that 
it  can  readily  be  pressed  in  with  the  fingers.  Anaesthetize. 
The  corono-pedal  articulation  can  be  felt,  about  3  cm.  below 
the  coronary  band,  by  grasping  the  claw  with  the  left  hand 
in  such  a  manner  that  the  thumb  rests  upon  the  thinly 
rasped  horn  while  with  the  other  hand  the  claw  is  moved 
from  side  to  side.  At  the  lowest  point  of  the  articulation 
push  the  sage  knife  into  the  joint,  the  concavity  of  the 
knife  being  directed  toward  the  leg,  and  make  a  curved  in- 
cision at  first  forward  and  upward  to  the  neighborhood  of 
the  coronary  band,  then  with  strong  flexion  of  the  foot  a 
second  curved  incision  backward  and  upward  which,  how- 
ever, extends  only  to  the  navicular  bone.  By  this  incision 
the  operator  divides  the  horn,  the  sensitive  lamina,  the  ex- 
ternal corono-pedal  ligament  and  the  capsular  ligament  of 
the  corono-pedal  articulation.  Pass  the  knife  between  the 
navicular  and  pedal  bones  and  extend  the  incision  down- 
wards perpendicular  to  the  solar  surface  through  it,  sepa- 
rating the  navicular  bone  from  the  os  pedis.  In  this  manner 
the  navicular' bone  is  preserved  as  well  as  the  ball  of  the 
heel,  the  latter  of  which  is  of  special  significance  in  healing. 
The  inner  wall  of  the  claw  with  the  powerfully  developed 
corono-pedal  ligament  is  divided  from  before  backward. 
After  the  vessels  which  can  be  seen  are  ligated,  the  articular 
surfaces  of  the  navicular  and  coronary  bones  curetted  and 
the  necrotic  remnants  of  tendon  removed  an  antiseptic 
bandage  is  applied  and  a  tar  bandage  placed  over  it  for  pro- 
tection.    The  bandage  remains  for  12  or  14  days. 

If  the  structures  above  this  point  of  amputation  are 
irremediably  involved  the  digit  should  be  amputated  higher 
up,  at  the  articulation  of  the  first  and  .second  phalanges  or 
through  the  first  phalanx.  In  these  higher  amputations  a 
flap  operation  is  generally  practicable. 


Plate  XXXV. 

Amputation  of  the  Claws  of  Ruminants. 

Fig.  I.  d,  horny  wall,  rasped  thin  ;  g,  artic- 
ular condyle  of  2nd  phalanx  ;  a,  b,  c,  course  of 
incision. 

Fig.  2.  Median  claw  preserved.  Viewed 
from  the  solar  surface  outward.  a,  external 
corono-pedal  ligament ;  /,  internal  do  ;  k,  ten- 
don of  the  flexor  pedis  muscle ;  g,  distal  artic- 
ular surface  of  the  2nd  digit ;  g'  articular  sur- 
face of  3rd  digit  ;  g",  navicular  bone  ;  /,  lateral 
claw  ;  ;;/,  median  claw  ;  b,  bulb  of  the  heel. 


Fig.  2. 


THE  BAYER  SUTURE.  209 

45.    THE  BAYER  SUTURE. 
Figs.   16  and  17. 

Uses.  The  closure  of  large  or  penetrant  wounds  with 
convenient  and  secure  means  for  applying  and  retaining 
antiseptic  dressings. 

Instruments.  Large  curved  suture  needle  armed  with 
strong  silk  thread,  about  20  cm.  long,  which  is  doubled  and 


Fig.  16. 

Retention,  and  Continuous  Approximation  Sutures. 

d,  d\  d" ,  drainage  tubes  ;  t\  retention  suture  (closed  end);  e' ,  open 
end  ;  b,  fixation  suture  for  the  drainage  tube  ;  f,  continuous  approxi- 
mation suture. 

passed  through  the  needle  eye  in  such  a  manner  that  the  loop 
extends  considerably  beyond  the  cut  ends  ;  small  needles 
and  thread  ;  needle  forceps  ;  rubber  tubing  preferably  two 
large  pieces  and  one  small  with  lateral  openings  ;  thin  wooden 

14 


2IO  THE  BAYER  SUTURE. 

splints  15  cm.  long,  2  to  4   cm.  wide,  with   rounded   ends  ; 
iodoform  gauze  ;  iodoform  ether  1:10. 

Technic.  After  the  skin  has  been  shaved  over  an  area 
having  a  radius  of  5  to  6  cm.  from  the  wound,  the  suture 
needle  is  inserted  2  to  3  cm.  from  the  lips  through  the  skin 
and  subjacent  tissues,  a  piece  of  the  rubber  tubing,  d' ,  passed 


Fig.  17. 

Splint  Bandage. 

d,  d\  d" ,  drainage  tubes  ;  t%  retention  siiture  (closed  ends);  e' ,  do, 
open  end  ;  j,  iodoform  gauze  ;  ^,  splints. 

through  the  closed  end  of  the  suture  and  the  thread  drawn 
tight.  If  before  threading  the  needle  a  clove  hitch  is  made 
at  the  middle  of  the  thread,  or  if  threaded  as  above  directed 
and  the  thread  is  thrown  about  the  tube  in  a  double  noose, 
the  two  threads  will  be  kept  in  contact  as  they  leave  the  tube 
to  enter  the  soft  tissues  and  thus  prevent  to  some  degree, 
the  pressure  necrosis  otherwise  taking  place,  due  to  the  tense 


THE  BA  YER  SUTURE.  21 1 

threads  of  the  suture  separating  from  each  other.  The 
needle  is  then  passed  through  the  opposite  lip  of  the  wound 
from  within  to  without  at  the  same  distance  from  the  lips, 
the  needle  removed,  the  free  ends  drawn  taut  and  a  single 
knot  tied  against  the  skin  to  prevent  the  separation  of  the 
two  threads  for  the  reasons  just  stated  above.  The  second 
large  tube,  d" ,  is  laid  between  the  open  ends  of  the  double 
silk  thread  and  these  are  tied  upon  it  with  a  triple  knot, 
after  they  have  been  drawn  sufficiently  tight  that  the 
approximated  wound  lips  form  a  crest.  If  the  lips  of  the 
wound  can  be  grasped  with  the  hand  and  held  together  in 
such  a  manner  as  to  form  a  ridge  3  or  4  cm.  long,  the 
suture  needle  may  be  passed  through  both  simultaneously. 
The  first  suture  should  be  located  about  3  cm.  beneath  the 
upper  angle  of  the  wound,  the  other  retention  sutures  follow 
at  distances  of  about  5  cm.  from  each  other  and  applied  in 
the  same  way. 

The  lips  of  the  wound  are  then  united  by  continuous 
approximation  sutures  like  an  overcasted  seam.  This 
suture  ends  at  least  2  cm.  above  the  lower  angle  of  the 
wound.  The  third  tube,  for  drainage,  is  introduced  be- 
neath the  latter  sutures  and  fixed  by  a  special  suture. 

The  entire  cutaneous  surface  lying  between  the  drainage 
tubes  is  covered  with  iodoform  gauze,  and  between  each  two 
retention  sutures  there  is  laid  over  this  gauze  the  wooden 
splints  previously  cut  to  the  proper  size,  the  ends  of  which 
are  pushed  under  the  tubing.  The  upper-  and  lowermost 
splints  should  be  secured  to  the  drainage  tubing  by  means 
of  sutures  passed  through  them.  The  entire  bandage  is 
finally  saturated  with  iodoform  ether.  The  bandage  and 
retention  sutures  remain  eight  days,  the  approximation 
sutures  fourteen. 


II.     EMBRYOTOMY  OPERATIONS. 

Fig.  18. 

General  Considerations.  The  following  exercises  in 
embryotomj'  operations  are  designed  to  give  to  the  student 
a  general  view  of  the  subject  by  a  simple  plan  as  carried 
out  through  the  aid  of  a  skeleton  provided  wnth  an  artificial 
uterus  into  which  are  placed  freshly  killed,  newly  born 
calves  in  such  a  position  as  may  be  desired  and  the  opera- 
tions carried  out  by  the  student  as  described.  At  the  same 
time  it  is  hoped  to  offer  through  these  descriptions  to  the 
veterinary  obstetrist  a  simple  and  effective  plan  for  perform- 
ing embryotomy  which  has  been  fully  tested  by  the  author 
in  an  extensive  obstetrical  practice.  In  describing  these 
operations  we  purposely  limit  the  instruments  to  be  used  to 
the  fewest  number  and  simplest  kinds,  yet  using  all  that  are 
essential  in  the  performance  of  any  of  the  following  obstet- 
rical operations.  We  designate  the  same  instruments  for 
each  operation.  They  are,  see  Fig.  i8  :  a  hooked  ring  knife; 
a  Colin's  scalpel  ;  an  embryotomy  chisel  ;  long  blunt  hook  ; 
short  blunt  hook  ;  repeller  ;  probe  pointed  sector  ;  injection 
pump  ;  mallet  ;  several  cotton  ropes  i  cm.  in  diameter  with 
a  small  spliced  loop  at  one  end. 


46.     CEPHALOTOMY. 


Object.  The  diminution  of  the  size  of  the  head  on  ac- 
count of  its  oversize  or  of  the  smallness  of  the  maternal 
pelvis,  so  that  it  may  pass  through  the  pelvic  canal. 

Technic,  In  these  cases  the  head  is  usually  engaged  in 
the  canal  sufficiently  tight  that  no  further  fixation  is  neces- 
sary. Should  further  fixation  be  desired,  fix  the  long  blunt 
hook  deeply  in  one  orbit.  After  thoroughly  cleansing  and 
disinfecting  the  parts  inject  a  copious  amount  of  tepid  lysol 


CEPHALOTOMY. 


213 


or  bacterol  solution  into  the  vagina,  then  carry  the  chisel 
carefully  guarded  by  one  hand  into  the  passage  and  place 
it  accurately  upon  that  part  of  the  head  of  the  fetus  where 
it  is  desired  to  begin  the  operation  ;  generally  on  the  median 
line  of  the  nose  with  the  blade  of  the  chisel  standing 
parallel  to  the  septum  nasi  of  the  fetus.     Holding  the  blade 


Fig.  18. 

Aseptible  Embryotomy  Outfit. 

A,  embryotomy  chisel ;  B,  repeller  ;  C,  sector  ;  D,  long  blunt 
hook  ;  E,  short  blunt  hook  ;  F,  ring  knife  ;  G,  hook  knife ;  H, 
Colin's  scalpel.  The  lower  figure  represents  the  entire  set  with 
injection  pump  arranged  in  aseptible  metal  case. 


2 1 4  DE  CAPITA  TION. 

ot  the  chisel  firmly  against  the  part  with  one  hand  in  such 
a  manner  as  to  effectively  guard  the  instrument  from  slip- 
ping aside  and  wounding  the  maternal  organs,  steady  and 
direct  the  handle  with  the  other  hand  and  have  an  assistant 
drive  the  chisel  by  means  of  blows  of  proper  vigor  with  the 
mallet  into  the  bones  of  the  face  and  head.  Do  not  drive 
the  chisel  deeper  than  the  length  of  the  blade  without  stop- 
ping and  forcibly  revolving  it  upon  its  long  axis  and  break- 
ing the  foetal  bones  apart.  The  partially  detached  pieces  of 
bone  may  be  torn  away  with  the  fingers  or  in  case  the  skin 
is  quite  adherent  to  them  the  bone  may  be  held  with  the 
fingers  of  one  hand,  the  chisel  introduced  with  the  other 
and  using  it  as  a  spatula  complete  the  separatioi;.  Repeat 
the  use  of  the  chisel  as  often  as  may  be  necessary  in  order 
to  bring  about  the  required  diminution  of  the  head,  care 
being  taken  at  all  times  not  to  wound  the  maternal  parts 
and  to  conserve  as  far  as  practicable  the  skin  of  the  fetal 
face  and  head  in  order  that  it  may  protect  the  maternal 
parts  from  the  jagged  bones  during  the  passage  of  the  re- 
mains of  the  head.  The  removal  of  the  partially  detached 
pieces  of  bone  may  in  many  cases  be  greatly  facilitated  by 
looping  a  cord  over  them  and  having  an  assistant  apply 
traction  sufficient  to  pull  them  away,  the  operator  guarding 
the  maternal  organs  by  holding  the  piece  of  bone  during  its 
detachment  and  extraction,  in  the  palm  of  his  hand. 


47.     DECAPITATION. 

Objects.  The  facilitation  of  repulsion  and  correction  of 
the  deviation  of  fetal  parts.  The  operation  is  generally  car- 
ried out  when  the  fetal  head  is  far  advanced  in  the  pelvic 
canal  or  has  passed  beyond  the  vulva. 

Technic.  Attach  a  cord  to  the  inferior  maxilla  or  around 
the  neck  of  the  fetus  and  have  one  or  more  assistants  draw 
the  head  out  as  far  as  possible. 


SUBCUTANEOUS  A  MFC  'TA  TION.  2 1 5 

Some  obstetrists  have  found  difficulty  in  applying  traction 
to  the  inferior  maxilla  by  means  of  a  cord.  First  make  a 
perforating  wound  with  the  knife  between  the  rami  of  the 
lower  jaw,  then  carry  the  looped  cord  over  the  jaw  and  push 
it  beyond  the  perforating  incision  with  the  loop  resting 
within  the  mouth  and  finally  pass  the  free  end  of  the  cord 
through  the  perforation  from  the  buccal  cavity  outwards, 
and  drawing  upon  this  the  inferior  maxilla  is  so  engaged 
that  it  will  permit  the  application  of  powerful  traction. 

Make  a  circular  incision  through  the  integument  encir- 
cling the  head  at  a  convenient  point  and  separate  the  skin 
backward  toward  the  occiput  by  forcing  the  hand  between 
it  and  the  bones  or  by  using  the  chisel  as  a  spatula  or 
dissecting  it  away  with  the  Colin's  scalpel,  continuing  the 
separation  over  the  occiput  to  the  atloid  region.  Make  a 
transverse  incision  below  across  the  trachea  and  oesophagus 
and  surrounding  muscles  and  above  through  the  ligamentum 
nuchae.  Grasp  the  head  firmly  with  both  hands  and  twist 
it  forcibly  on  its  long  axis  rupturing  the  articular  ligaments 
and  the  remaining  muscles  and  other  soft  tissues,  detaching 
the  head  at  the  occipito-atloid  articulation.  The  removal 
of  the  head  greatly  diminishes  the  bulk  of  the  fetus  and  it 
may  now  be  repelled,  or  deviated  parts  brought  into  the 
desired  position  or  other  operations  performed. 


48.    SUBCUTANEOUS    AMPUTATION    OF    ANTERIOR   LIMBS. 

Objects.  Amputation  of  the  anterior  limbs  is  very 
frequently  called  for  in  obstetric  practice  especially  in  the 
mare,  chiefly  in  cases  of  transverse  presentation  with  all 
four  feet  presenting  and  the  head  retained  where  it  may  be 
impossible  to  safely  correct  the  deviation  ;  in  cases  of  wry 
neck  in  the  foal  in  the  anterior  presentation,  when  it  is 
impossible  to  correct  the  deviation  of  the  head,  or  in  any 
case  in  the  mare  or  cow  where  deviation  of  the  head  cannot 


2 1 6  SUBCL  TANEOUS  AMPUTA  TION. 

be  corrected  or  is  not  so  readily  overcome  as  is  the  amputa- 
tion of  the  limb. 

Technic.  Our  herbivorous  animals  being  devoid 
of  a  clavicle,  the  anterior  limb  is  attached  to  the  thorax  by 
means  of  the  skin  and  muscles  only  and  is  therefore  compar- 
atively easily  amputated.  Attach  a  cord  to  the  pastern  of 
the  limb,  the  shoulder  of  which  lies  most  exposed  or  is  most 
readily  reached  and  have  one  or  two  assistants  exert  traction 
on  it  and  draw  it  out  as  far  as  possible  with  safety  to  the 
mother.  Insert  one  hand  armed  with  the  hooked  embry- 
otomy knife  up  to  the  top  of  the  scapula  or  as  nearly  thereto 
as  can  be  reached,  the  knife  being  well  guarded  in  the  palm 
of  the  hand  which  rests  against  the  limb  of  the  fetus  ;  press 
the  knife  into  the  skin  and  subcutaneous  tissues  and  drawing 
the  hand  downward  slit  them  freely  and  deeply  from  the  top 
of  the  scapula  down  to  the  pastern.  Lay  aside  the  knife  and 
force  the  fingers  between  the  skin  and  subjacent  tissues  of 
the  limb  and  while  the  assistant  maintains  gentle  traction, 
separate  the  skin  upward  by  forcing  the  hand  or  the  ball  of 
the  thumb  through  the  loose  connective  tissue  until  the 
upper  region  of  the  scapula  is  reached.  The  separation  of 
the  skin  from  the  subjacent  parts  may  require  at  certain 
points,  like  the  olecranon  or  carpus,  the  aid  of  the  chisel 
or  knife  to  divide  firm  bands  of  connective  tissue.  This 
separation  of  the  skin  from  the  subjacent  parts  has  removed 
the  chief  source  of  resistance  to  the  tearing  of  the  limb 
away  from  the  body.  The  next  most  important  obstacle  is 
the  pectoral  muscles  which  should  be  torn  asunder  by  sep- 
arating them  into  small  bundles  and  tearing  them  through 
with  the  fingers  between  the  sternum  and  limb,  or  the  pro- 
cess may  be  aided  by  incision  with  a  knife  or  the  chisel. 
When  these  are  well  divided  the  remaining  impediment  to 
tearing  the  shoulder  away  consists  largely  of  the  trapezius 
and  rhomboideus  muscles  at  the  top,  the  latissimus  dorsi  be- 
hind, the  great  serratus  and  the  angularis  scapula  which 


SUBCUTANEOUS  AMPUTATION. 


217 


only  come  into  action  when  the  shoulder  is  nearly  severed. 
It  is  only  necessary  then  to  separate  ttie  skin  from  the  limb 
and  divide  the  pectoral  muscles  in  order  to  readily  draw  the 
limb  away  by  traction.  Divide  the  skin  now  around  the 
pastern  and  have  two  or  three  assistants  exert  traction  upon 
the  limb  while  the  operator  places  his  hand  against  the 
sternum  and  pushes  in  the  opposite  direction.  Or  the  op- 
erator may  increase  his  repulsion  by  using  the  repeller  and 
pushing  upon  the  crutch  with  his  hand  while  an  assistant 
pushes  upon  the  repeller  handle.  The  impact  upon  the 
maternal  organs  due  to  the  traction  may  be  reduced  to  al- 
most any  desired  degree  by  applying  a  corresponding  degree 
of  repelling  force  to  the  sternum  of  the  fetus.  If  the  re- 
pelling force  applied  to  the  fetal  sternum  equals  the  traction 
upon  the  limb  the  impact  of  the  fetus  against  the  maternal 
organs  becomes  nil. 

If  traction  does  not  bring  the  limb  away  promptly  the 
operator  should  attempt  to  extend  the  division  of  the 
muscles  attaching  the  limb  to  the  thorax  while  moderate 
traction  upon  the  limb  is  continued. 

Further  diminution  of  the  size  of  the  fetus  may  now  be 
had  by  removal  of  the  other  limb  in  the  same  way  which  is 
especially  desirable  in  the  transverse  presentation  with  all 
four  limbs  in  the  passages  or  we  may  reduce  the  size  of  the 
trunk  by  evisceration  as  described  under  54. 

This  diminution  suffices  to  permit  the  remnant  of  the 
fetus  to  be  withdrawn  with  the  head  deviated  to  the  side, 
the  total  resistance  being  no  greater  than  had  the  head  and 
neck  presented  normally.  It  also  renders  the  fetal  body 
very  flaccid,  and  easy  of  repulsion  and  simplifies  the  cor- 
rection of  any  deviations  of  parts. 


2 1 8  DETR  UNCA  TION. 

49.     AMPUTATION  AT  HUMERO-RADIAL  ARTICULATION. 

Object.  Amputation  at  this  point  is  rarely  desirable,  but 
may  at  times  be  necessary  in  the  mare  in  order  to  remove 
an  anterior  limb  when  it  is  impossible,  on  account  of  the 
position  to  reach  the  shoulder. 

Technic.  Attach  a  cord  to  the  pastern  and  have  an 
assistant  render  the  leg  tense  by  exerting  moderate  traction, 
as  in  the  preceding.  Introduce  the  hand  armed  with  the 
embryotomy  knife,  carefully  concealed  in  the  palm,  and 
girdle  the  skin  around  the  articulation.  Passing  above  the 
head  of  the  olecranon  on  the  posterior  side,  divide  the 
attachment  of  the  anconean  group  of  muscles  with  the 
knife  by  cutting  from  behind  forward.  Then  divide 
transversely,  as  far  as  possible,  the  muscles  and  ligaments 
passing  over  the  articulation.  Rotate  the  limb  forcibly  on 
its  long  axis  while  strong  traction  is  maintained,  and  rup- 
ture the  principal  ligaments  until  the  limb  is  completely 
detached  and  comes  away.  In  cases  of  limited  room  it  may 
sometimes  be  easier  to  detach  the  skin  of  the  limb  from  the 
pastern  up  to  the  articulation,  as  in  the  preceding  chapter, 
rather  than  to  girdle  it. 


50.     DETRUNCATION. 
Plate  XXXVI. 


Object.  In  case  a  fetus  in  the  anterior  presentation  and 
dorso-sacral  position  has  one  or  both  posterior  limbs  devi- 
ated forward  and  the  feet  engaged  in  or  against  the  pelvis,  it 
may  be  necessary,  or  at  least  advisable  in  the  mare,  that  the 
trunk  of  the  fetus  be  divided  in  order  to  bring  about  delivery 
without  serious  or  fatal  injury  to  the  mother. 

Technic.  Secure  the  two  hind  feet  by  means  of  cords, 
if  possible,  prior  to  other  manipulations.  Apply  cords  to 
the  two  anterior  limbs  and  the  head,  have  one  or  two  assist- 
ants draw  the  anterior  part  of  the  fetus  as  far  out  as  is  prac- 
ticable and  safe,  and  then  girdle  the  fetal  body  immediately 


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222        DESTRUCTION  OF  THE  PELVIC  GIRDLE. 

against  the  maternal  vulva  by  making  an  incision  through 
the  skin  and  skin  muscle.  If  practicable  it  is  best  at  this 
point  to  remove  one  shoulder  subcutaneously,  (48),  and  fol- 
low by  evisceration,  (54),  in  order  to  give  greater  opera- 
tive room  and  increased  mobility  of  the  fetus.  Insinuate 
the  hand  between  the  skin  and  the  deeper  structures  and 
forcibly  separate  the  integument  from  the  fetal  body  back- 
ward until  the  last  rib  is  passed,  as  shown  at  the  curved 
line  in  Plate  XXXVI.  Force  the  finger  tips  through  the 
abdominal  wall  behind  the  last  rib  and  passing  along  the 
entire  border  of  each  posterior  rib,  separate  the  abdominal 
walls  from  the  ribs  and  sternum.  After  the  abdominal 
muscles  have  been  detached,  and  the  fetus  has  been  evis- 
cerated, rotate  the  thorax  upon  its  long  axis  which 
will  cause  a  division  of  the  vertebral  column  near  the  dorso- 
lumbar  articulation  and  the  anterior  portion  of  the  fetus 
falls  away. 

Secure  the  two  posterior  feet  with  cords,  unless  this  has 
already  been  done,  spread  the  detached  skin,  which  has 
been  pushed  back  from  the  thorax,  carefully  over  the 
amputation  stump  of  the  lumbar  vertebrae,  repel  these  by 
means  of  the  hand  while  an  assistant  draws  upon  the  cords 
attached  to  the  feet,  push  the  remnant  of  the  fetal  trunk 
into  the  uterus  and  advance  the  feet  along  the  genital  pass- 
ages, thus  converting  it  into  a  posterior  presentation. 
Ordinarily  this  would  result  in  a  dorso-pubic  —  which 
should  be  converted  into  the  dorso-sacral  position,  when 
its  extraction  can  be  readily  brought  about. 


51.     DESTRUCTION    OF    THE    PELVIC    GIRDLE    IN    THE 
ANTERIOR  PRESENTATION. 

Plate  XXXVII. 
Object,      [n  somewhat  rare  instances  perhaps  most  fre- 
quently in  the  cow  the  pelves  of  the  mother  and   fetus  be- 
come  interlocked,  the   antero-external   angle  of    the  fetal 
ilium,  r,  becoming  locked  with  the  shaft  of   the  maternal 


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2  26     AMPUTA  TION  OF  THE  LIMBS  A  T  THE  TARSUS. 

ilium  I  at  C  in  such  a  manner  that  any  safe  degree  of  trac- 
tion fails  to  dislodge  it. 

Technic.  Remove  one  anterior  limb  subcutaneously, 
(48),  and  eviscerate,  (54),  through  an  opening  made  by 
the  removal  of  two  or  three  of  the  exposed  ribs.  Introduce 
the  chisel  through  this  opening  and  carry  it  back  with  the 
hand,  place  it  against  the  shaft  of  the  fetal  ilium,  I',  have 
an  assistant  drive  it  through  the  shaft  from  before  to  behind 
and  then  withdrawing  the  chisel  replace  it  against  the  pubic 
brim  either  at  the  symphysis  pubis  or  opposite  the  obturator 
foramen,  and  drive  it  through  the  pubis  and  ischium  at 
either  of  these  points.  The  coxo- femoral  articulation  is  thus 
detached  and  isolated  so  that  the  entire  limb  may  drop 
backward  beyond  its  fellow,  the  remnant  of  the  severed 
ilium,  I',  can  drop  downward  or  move  in  any  direction  and 
the  entire  pelvis  thus  loses  its  rigidity  and  undergoes  great 
diminution  in  size  so  that  it  can  readily  be  withdrawn. 


52.    AMPUTATION  OF  THE  LIMBS  AT  THE  TARSUS. 
Plate  XXXVIII. 

Object.  It  sometimes  happens  in  the  mare,  far  more 
rarely  in  the  cow  that  in  the  posterior  presentation  with  the 
hind  limbs  retained  at  the  hock  owing  to  the  unusual  size 
of  the  fetus  or  its  having  been  dead  for  some  time,  dry  and 
emphysematous,  that  the  deviation  can  not  be  overcome  or 
its  correction  would  entail  an  unnecessary  amount  of  labor. 
In  these  cases  it  is  frequently  easier  for  the  obstetrist  and 
safer  for  the  mother  to  amputate  the  limb  at  the  tarsus. 

Technic.  Pass  a  cord  around  the  leg  above  the  tarsus 
as  indicated  in  Plate  XXXVIII  and  have  an  assistant  hold 
the  leg  steady  by  gentle  traction.  Introduce  the  chisel 
carefully  guarded  in  the  palm  of  the  hand,  and  place  it 
against  the  lower  part  of  the  tarsus  as  shown  between  T,  T. 
The  chisel  should  be  placed  as  nearly  as  possible  perpen- 


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230 


INTRA-rEL  VIC  AMPUTA  TION. 


dicular  to  the  long  axis  of  the  metatarsus.  The  proper  direc- 
tion of  the  chisel  may  at  times  be  greatly  favored  by  placing 
the  cord  upon  the  metatarsus  instead  of  the  tibia  thus  forc- 
ing the  tarsus  toward  the  sacrum  of  the  mother  and  tending 
to  throw  the  metatarsus  straight  across  the  pelvic  cavity. 
When  the  fetus  is  in  the  dorso-sacral  position  and  it  is 
desired  to  amputate  the  left  limb,  the  chisel  should  be  held 
in  the  palm  of  the  left  hand  with  its  dorsal  surface  against 
the  vaginal  walls  and  the  instrument  carefully  guarded  and 
guided  during  the  entire  operation.  The  amputation  should 
preferably  be  through  the  lower  section  of  the  tarsus  but 
may  be  made  through  the  head  of  the  metatarsus.  Do  not 
drive  the  chisel  entirely  through  the  hock  without  removal 
as  it  may  become  caught  and  clamped  between  the  divided 
bones,  but  drive  for  a  few  inches  along  the  lateral  side  being 
sure  that  the  skin  at  that  point  is  severed  along  with  the 
bone,  then  loosen  the  chisel  by  rotation  and  lateral  motion 
and  drive  somewhat  deeper  into  the  tarsus  until  it  is  com- 
pletely severed.  Withdraw  the  severed  metatarsus  and  re- 
move any  dangerous  spicules  of  bone  remaining  on  the 
stump  and  see  that  the  latter  is  safely  secured  by  a  cord 
passing  around  the  leg  above  the  os  calcis.  Repeat  the 
operation  on  the  other  hock  in  a  similar  manner  using  the 
right  hand  to  guide  the  chisel.  Extend  the  two  limbs  into 
the  passages  by  traction  and  effect  a  posterior  delivery. 


53.     INTRA-PELVIC  AMPUTATION  OF  THE  POSTERIOR 
LIMBS,  BREECH  PRESENTATION. 

Plates  XXXIX-XL. 

Uses.  The  overcoming  of  dystocia  due  to  a  posterior 
presentation  with  the  hind  limbs  completely  retained  in  the 
uterus,  the  so-called  breech  presentation,  in  cases  where  the 
deviation  can  not  be  readily  corrected. 

Technic.  Introduce  one  hand  armed  wnth  the  embry- 
otomy knife  through  the  maternal  passages  until  the  peri- 


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INTRA-PEL  J  'IC  AMPUTA  TION. 


neum  of  the  fetus  is  reached  and  make  a  free  incision 
through  that  region  involving  the  anus  in  the  male  fetus 
and  the  anus  and  vulva  in  the  female  and  enlarge  the 
incision  sufficiently  to  admit  the  operator's  hand  into  the 
fetal  pelvis.  Locate  the  great  sciatic  ligament  and  with  the 
knife  divide  the  ligament  from  end  to  end,  thus  enlarging 
the  pelvic  cavity  and  giving  ample  operating  room.  If  the 
pelvis  of  the  fetus  is  too  small  to  admit  the  hand  of  the 
operator  at  all  before  severing  the  sciatic  ligament,  this 
may  be  accomplished  by  cautiously  cutting  from  behind 
forward  with  Colin's  scalpel  or  with  the  chisel.  When  this 
has  been  severed  and  sufficient  operating  room  attained, 
carry  the  chisel  with  the  hand  and  place  it  against  the  shaft 
of  the  ilium  as  shown  between  I'  I'  in  Plate  XXXIX  as 
nearly  perpendicular  to  the  long  axis  of  the  iliac  shaft  as 
possible  and  keeping  the  hand  in  touch  with  the  chisel  blade, 
have  an  assistant  drive  it  through  the  bone  until  it  and  its 
periosteum  are  completely  severed.  Revolve  the  chisel  on 
its  long  axis  and  force  the  cut  ends  of  the  bone  apart.  Dis- 
engage the  chisel  and  place  it  against  the  symphysis  pubis 
or  against  the  ischium  opposite  the  obturator  foramen  and 
drive  it  through  the  ischium  and  pubis  at  this  point.  Using 
the  chisel  as  a  lever,  separate  the  isolated  portion  of  the 
pelvis  as  completely  as  practicable  from  the  surrounding 
tissues,  and  with  the  fingers  separate  the  muscles  from  the 
detached  pelvic  bone  for  a  short  distance  from  the  severed 
ends  on  either  side.  Carry  a  cord  in,  pass  the  loop  over  the 
ends  of  the  severed  section  and  tightening  it  secure  the  iso- 
lated portion  of  the  pelvis  and  have  one  or  more  assistants 
exert  traction  as  indicated  in  Plate  XL.  The  chief 
obstacle  to  the  withdrawal  of  the  limb  is  the  great  gluteus 
muscle  which  should  be  sought  for,  identified  and  torn 
through  with  the  fingers  at  a  distance  of  5  or  6  cm.  from 
its  attachment  to  the  great  trochanter.  Other  important 
points  of  resistance  are  the  attachment  posteriorly  of  the 
skin,  vulva  and  anus  to  the  ischium  through  the  medium 


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238  INTRA- PEL  VIC  AM  PL  'TA  TION. 

of  aponeurosis  and  anteriorlj',  chiefly  on  the  median  line, 
the  prepubic  tendon  ;  these  are  to  be  cut,  if  necessary,  with 
the  chisel  or  knife.  Vigorous  traction  may  now  be  applied 
by  means  of  the  cord,  the  operator  in  the  meantime  guard- 
ing the  most  advanced  end  of  the  detached  piece  of  pelvis 
with  the  palm  of  his  hand  in  order  to  prevent  injury  to  the 
maternal  organs.  Sometimes  this  detached  piece  of  the 
pelvis  tears  away  from  the  femur  when  traction  is  applied 
and  comes  away  alone.  In  such  a  case  the  cord  is  to  be 
applied  over  the  head  and  trochanter  of  the  femur  and 
traction  again  applied  drawing  the  limb  away  in  a  reversed 
position,  the  skin  being  turned  back  or  everted  as  it  ad- 
vances until  the  region  of  the  hock  is  reached  where  the 
integument  does  not  so  readily  separate  and  only  requires 
to  be  cut  loose  and  the  member  allowed  to  come  away. 
During  the  removal  of  the  limb  the  operator  is  to  con- 
stantly note  the  progress  with  his  hand  and  sever  by  tearing 
of  cutting  any  tendons  or  muscles  which  offer  special 
obstruction  to  the  operation.  Repeat  the  operation  upon 
the  opposite  limb  in  the  same  manner  except  that  but  one 
incision  need  be  made  through  the  bone,  that  is,  through 
the  shaft  of  the  ilium.  During  the  entire  work  the  opera- 
tion is  carried  out  subcutaneously  or  rather  intra-fetally 
and  the  maternal  parts  are  amplj^  guarded  against  injury. 
The  size  of  the  fetal  trunk  may  be  further  reduced  if  de- 
sirable, by  evisceration,  (54),  and  followed  still  further  by 
the  introduction  of  the  chisel  guided  by  the  hand  and  the 
ribs,  on  one  or  both  sides,  severed  one  after  another  until 
the  chest  can  completely  collapse.  Or  the  ribs  may  be  yet 
more  conveniently  severed  by  introducing  the  sector  in  the 
body  cavity,  pushing  it  forward  until  the  first  rib  is  reached 
catching  the  spherical  end  over  the  rib  and  drawing  back- 
wards, sever  each  rib  in  turn.  If  need  be  some  of  these 
may  be  removed  and  one  of  the  anterior  limbs  caught  by  a 
cord  around  the  scapula  and  extracted  intra-fetally.  The 
remnant  of  the  fetus  is  to  be  extracted  by  means  of  a  cord 
fastened  about  the  lumbar  region  of  the  spine. 


E  J  'ISCERA  TION.  239 

54.     EVISCERATION. 

Evisceration  of  the  fetus  is  frequently  desirable  in  ob- 
stetric practice  and  has  a  variety  of  uses.  It  decreases  the 
size  of  the  fetal  trunk  considerably  and  permits  its  more 
ready  passage  through  the  genital  canal,  as  in  the  anterior 
presentation  ;  with  lateral  deviation  of  the  head  it  renders 
the  fetal  trunk  flaccid  through  the  removal  of  the  viscera 
supporting  the  body  walls  and  permits  the  body  remnant  to 
be  bent  or  moved  more  readily  for  the  correction  of  any  mal- 
presentation  ;  it  permits  freedom  of  intra-fetal  operations 
•directed  against  other  parts,  as  for  detruncation,  or  for  the 
•destruction  of  the  pelvic  girdle  in  the  anterior  presentation, 
and  when  a  fetus  is  emphysematous,  evisceration  permits 
the  gases  of  decomposition  to  pass  into  the  fetal  body  cavity 
and  thence  externally.  The  escape  of  gases  is  very  greatly 
favored  further  by  the  cutting  of  the  ribs. 

Technic.  Evisceration  may  be  variously  performed,  but 
is  generally  demanded  in  either  the  anterior  or  posterior 
presentation  and  a  description  of  these  will  suffice. 

In  the  anterior  presentation,  unless  the  fetus  is  far  ad- 
vanced through  the  vulva,  evisceration  is  best  performed  by 
the  removal  of  one  or  more  of  the  anterior  ribs.  The  ribs 
are  generally  best  reached  by  the  removal  of  the  shoulder, 
as  already  described  under  subcutaneous  amputation  of  the 
anterior  limbs,  (48).  When  the  ribs  have  been  laid  bare  in 
the  manner  described  the  operator  can  thrust  the  finger  tips 
through  the  intercostal  muscles  in  the  first  space  and  enlarge 
the  opening  thus  made  by  tearing  through  the  muscles  up- 
wards to  the  spinal  column  and  downwards  to  the  sternum  ; 
then  grasping  the  posterior  border  of  the  rib  near  its  middle, 
fracture  it  by  means  of  a  sudden  and  vigorous  pull.  The 
fractured  ends  may  then  be  grasped  and  pulled,  broken  or 
twisted  off.  The  chisel  may  be  brought  into  use  if  required 
in  order  to  divide  the  rib,  the  hand  of  the  operator  con- 
stantly guiding  and  guarding  the  chisel  blade.     The  opera- 


240 


EVISCERATION. 


tion  is  then  to  be  repeated  if  required,  upon  the  second  and 
third  ribs  in  the  same  manner  until  an  opening  into  the 
chest  is  secured  ample  in  size  for  the  introduction  of  the 
operator's  hand. 

Force  one  hand  through  the  opening  and  tear  the  medi- 
astium  above  and  below  from  the  thoracic  walls,  and  then 
grasp  either  the  trachea  at  its  bifurcation  or  the  heart  and 
tear  them  awaj'.  The  heart,  which  constitutes  the  greater 
bulk  of  the  thoracic  viscera,  is  best  grasped  in  the  palm  of 
the  hand,  with  the  fingers  engaging  the  aorta  and  pulmo- 
nary arteries.  When  the  thoracic  viscera  have  been  with- 
drawn, thrust  the  fingers  through  the  diaphragm  and  locat- 
ing the  liver,  isolate  the  diaphragmatic  area  to  which  it  is 
attached,  and  engaging  both  with  the  fingers  remove  the  two 
together.  The  liver  constitutes,  in  a  normal  fetus,  the  chief 
intra-abdominal  mass,  occupying  more  space  than  all  other 
organs  combined.  After  the  liver  has  been  removed  the 
intestinal  tube,  with  its  contents,  is  withdrawn  without 
difficulty,  as  its  attachments  are  feeble.  The  kidneys  may 
also  be  removed. 

Evisceration  in  the  posterior  presentation  is  preferably 
performed  through  the  pelvis,  generally  in  connection  with 
intra-pelvic  amputation  of  the  posterior  limbs,  (53).  It 
may  be  performed  without  destruction  of  the  pelvic  girdle 
by  making  an  incision  through  the  perineal  region  and 
then  severing  the  sacro-sciatic  ligament  as  directed  under 
53.  When  admission  has  been  gained  to  the  abdominal 
cavity  introduce  the  hand  and  withdraw  the  alimentary 
tube,  then  rupture  the  diaphragm  about  the  liver  and 
tear  away  the  latter  organ  in  the  same  manner  as  in  the 
anterior  presentation.  The  liver  is  so  friable  that  it  cannot 
well  be  removed  by  grasping  the  organ  itself,  but  c'omes 
away  entire  with  the  central  part  of  the  diaphragm. 

Remove  the  heart  and  lungs  as  above  directed. 


